​Root-cause analysis requires a systematic, intensive, and in-depth review in order to determine the most basic reasons for an adverse event. This approach has a formal logic and a defined methodology. The goal is to understand the problem in sufficient depth to effectively eliminate the risk of future injury. Sometimes root-cause analysis is performed to analyze a single event.

Other times a number of events, like medication errors, are aggregated so that patterns can be identified and system-wide changes can be made.

A root-cause analysis should include the following elements:

  • An interdisciplinary team review;
  • An on-site review of the location of the event;
  • Input solicited from the post-event report, resident assessment, staff, residents, and other witnesses to the event;
  • Recognition that there may be several “working” root causes; and
  • Involvement of key stakeholders, such as staff members and residents who are involved in or witnesses to the event.