One of the methods used to prevent medical errors is Root Cause Analysis (RCA).This is a process used to determine why a medical error occurred and how to prevent its reoccurrence. In hospitals and patient care facilities, the use of RCA is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

RCA in a hospital setting is triggered by a sentinel event. This can be an unexpected serious injury (whether psychological or physical) or death of a patient from a cause not related to the natural cause of the illness. The 20 most common sentinel events, according to JCAHO, are:

Patient suicide

Wrong-site surgery

Operative or postoperative complications

Medication error

Delay in treatment

Patient fall resulting in injury or death

Patient death or injury in restraints

Assault, rape, or homicide

Transfusion error

Perinatal death/loss of function

Patient elopement resulting in injury or death

Infection-related event resulting in injury or death

Fire

Anesthesia-related event resulting in injury or death

Ventilator death/injury

Maternal death

Medical equipment-related event resulting in injury or death

Abduction of any individual receiving care, treatment, or services

Discharge of an infant to the wrong family

Utility systems-related event resulting in injury or death

When a sentinel event occurs (or in some cases if it may occur), a team of not more than 10 people is assembled. They may conduct structured interviews, review documents and observe to establish a timeline detailing the sentinel event. Analysis of this data will look for failures (whether actual or latent) or absences (issues not addressed) in the system which contributed to the event. The focus is less on individual responsibility than on a broader picture.

At an early stage in the investigation, interim changes are devised and implemented. Then work continues to identify the systems involved in the event and their interrelationships. Ways to reduce the risk of the event reoccurring are then developed and implemented. The effectiveness of these actions is later evaluated.

RCA has been criticized. It may be susceptible to bias. One possible instance of bias is the cause of the moment being chosen as the root cause. For example, the previous focus on device malfunction has been shifted under RCA to staffing, management and information systems failures. The RCA process takes a good deal of time and properly trained personnel, both of which may be at a premium in a budget-stretched hospital setting.

One of the sentinel events is infant abduction. This is the policy one major hospital has implemented to combat this event:

At the time of birth, before exiting the delivery room, mother, father and newborn are banded with ID bands bearing the same number.

The staff of each unit wears a picture ID which is coded with the unit's color as well.

The patient is instructed to never give her baby to anyone who does not match their picture ID with the correct color coding.

When the nurse brings a baby to the mother, the nurse reads off the ID numbers on the baby's band and the parent or parents verifies the numbers on their bands by reading them back to the nurse. Continued ways are sought to shore up possible weak areas in patient protections.

Labor and delivery "Action Teams" are routinely formed. The job of the action team, consisting of staff members headed by a clinical supervisor, is to:

1. Formulate a problem.
2. Formulate an action plan.
3. From the plan, implement a policy.

For example, the problem formulated by the action team is the possibility of infant abduction. The scenario is an abductor getting pass security with an infant. A mock drill is performed. A person carrying a large bag might see if they can get pass security without a check.

If a hole in security is discovered, an action plan is formulated and a policy is put in place, directly addressing and preventing the possibility of abduction by those methods.