JCAHO has a very important role in cause analysis of medical errors. Since 1995, it has been increasing its focus on patient safety by requiring in-depth analysis, Root Cause Analysis, to determine the underlying causes of every adverse event.

Root causes are specific reasons that contribute to medical errors. They cause mistakes that lead to great patient harm (adverse events). Usually they can be identified.

Examples:

• Using a wrong calculation factor


• Neglecting to use directions for complicated tests


• Reporting the wrong test result


• Using outdated reagents


• Testing clotted or partially-filled samples
• Diluting a test sample incorrectly

In most cases, management has the authority and means to resolve root causes. Root Cause Analysis also recommends actions to prevent reoccurrence of an adverse event.