Abstract: The Root Cause Analysis method was used to analyze a case of identification error of a surgical patient. In order to reproduce the whole process of the case, the five key steps of RCA, namely defining the problem and gathering data, identifing possible causes, determining the root cause, generating plans and carrying out those plans were taken, which provided hospital managers with ideas and methods of quality management to better identify problems in the system and generate improvement plans and preventive measures.

Key words: Root Cause Analysis; identification; patient safety