Andrea Cassano-Piché, et. al2018-09-302018-09-302015http://hdl.handle.net/20.500.12091/390Root Cause Analysis (RCA) is a retrospective incident investigation framework, initially developed as a quality management engineering tool, that is now widely used in many industries to support the improved safety of systems following an accident or incident. In healthcare, regulators such as The Joint Commission have mandated immediate investigation and response following a sentinel event, which is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” [44]. RCA is a means by which this type of investigation and response can be accomplished.en-USHTMBook chapter