In normal chaotic organizational environments it is often quite difficult to find candidates for root cause analysis because the situations which repeat are either distributed over time so one doesn't realize they are actually recurring, or the situation happens to different people so there isn't an awareness of the recurring nature of the situation. (systems-thinking.org)

On receipt of initial notification, the department will provide the hospital with a sentinel event reference number to be indicated on the root cause analysis, risk reduction action plan summary and other correspondence about the episode. (Victorian State Government - Health)

Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues. (bill-wilson.net)