Root cause analysis in response to a "near miss".

Root cause analysis is a technique used in determining the real cause of an event. The Sentinel Event Policy of the Joint Commission on Accreditation of Healthcare Organizations requires a root cause analysis of a sentinel event but not a "near miss." However, root cause analysis is an important process for preventing another near miss from the same or similar cause. This article reviews the background of basic root cause analysis and provides an example of the process. Changes in policy and procedures for patient-controlled analgesia therapy, as a result of the root cause analysis, are described.