What is the primary goal of a root cause analysis after a sentinel event?

• A. Assign blame to determine accountability for the event.
• B. Identify underlying system failures, not individuals, and implement corrective actions to prevent recurrence.
• C. Document the event without implementing changes.
• D. Investigate only the department where the event occurred.

Answer: (B)

The main idea tested here is safety improvement through systemic change. After a sentinel event, the goal of a root cause analysis is to uncover underlying failures in processes, systems, communication, training, policies, equipment, or workflow—and to implement corrective actions that address those root causes across the organization to prevent recurrence. This approach shifts focus away from blaming individuals and toward strengthening the whole system, which is essential for real, lasting safety improvements.

If a response centers on assigning blame, it doesn’t help reduce risk or change how care is delivered. Merely documenting the event without making changes leaves the same vulnerabilities in place. Investigating only one department misses the interdependent factors and system-wide issues that can contribute to harm. By targeting systemic weaknesses and implementing corrective actions, the organization learns from the event and reduces the chance of it happening again.