Since 1996 the Joint Commission, which accredits American hospitals, has required “thorough and credible comprehensive systematic analyses (for example, root cause analyses)” after a sentinel event, a serious unexpected harm to a patient. The policy followed incidents at accredited hospitals in 1995, including the amputation of the wrong foot.
Twenty years later the field reviewed its own results. In 2015 the National Patient Safety Foundation proposed renaming the process “Root Cause Analysis and Action.” Reviewers found a “tendency to focus on weak solutions such as reminders, education, and training over stronger solutions.” Other studies “failed to demonstrate that the corrective actions drawn from RCAs have prevented” future harm.