A patient sustained a skull fracture as a result of an attack by another patient. A risk manager initiates a root cause analysis. Which of the following is the intended outcome of the investigation?

The primary purpose of a Root Cause Analysis (RCA) is to identify the underlying system-level vulnerabilities that led to an adverse event. It is a non-punitive process focused on learning from errors to prevent them from happening again. The intended outcome is the development of a robust action plan with specific, measurable interventions designed to eliminate or mitigate the identified root causes, thereby preventing recurrence. The focus is on improving systems and processes, not on assigning individual blame.

A. Interviewing staff is a crucial step during the RCA process to gather information, not the final intended outcome of the investigation.
C. Banning a patient is a punitive, reactive measure that fails to address the systemic issues that allowed the event to occur.
D. Determining disciplinary actions is contrary to the non-punitive, systems-focused philosophy of a root cause analysis, which seeks to prevent blame.

1. Agency for Healthcare Research and Quality (AHRQ). (2019). Root Cause Analysis. PSNet Patient Safety Network. Retrieved from https://psnet.ahrq.gov/primer/root-cause-analysis. (See section: "What is Root Cause Analysis?")

2. The Joint Commission. (2017). Framework for Conducting a Root Cause Analysis and Action Plan. (See section: "The RCA2 Process," which emphasizes developing actions to prevent recurrence).

3. U.S. Department of Veterans Affairs, National Center for Patient Safety. (2015). The Basics of Root Cause Analysis. (See slide 5, "Goals of RCA," which lists "recommend and implement solutions to prevent the event from ever happening again").