Hospital managers' experiences of conducting a root cause analysis: a case study following a sentinel event.

Background: Root cause analysis (RCA) is a method used in healthcare to systematically identify and address underlying causes of adverse or sentinel events to enhance patient safety and mitigate risks. This study explores hospital managers' experiences of conducting an RCA process following a sentinel event in which a baby unexpectedly died during labor at a Norwegian hospital in 2021. Method: The study employed a qualitative, exploratory single-case design, which involved conducting nine semi-structured interviews and analyzing documents such as the Norwegian RCA guideline, the final RCA report, and internal procedures and standards. The interviews were conducted between May and August 2021. Thematic analysis was used to organize and interpret the transcribed data. The research addressed the following question: Results: Two main themes emerged. The first theme Conclusion: The findings highlight the need for more precise role definitions, better resources, and stronger emotional support systems to strengthen RCA processes. Although national RCA guidelines provide a valuable framework, real-world constraints and unique circumstances often require adaptive approaches. This study emphasizes managers' pivotal role in bridging the gap between regulatory expectations and organizational realities, underscoring the need for both practical and emotional support to ensure effective RCA implementation in sentinel events.