Root Cause Analysis (RCA)

What is Root Cause Analysis?

A Root Cause Analysis (RCA), is a systematic process used in the identification of the root cause of a sentinel event with the aim of rectifying system flaws, which led to an undesired outcome (Cherukuri et al., 2017; Cherry & Jacob, 2016, p.380). While the process highlights the cause, it retrospectively focuses on correcting a wrong in the system rather than blaming an individual(s) for the problem. Organizations conduct an RCA as a means to provide long term solutions. When organizations address the effects of a problem and neglect the primary cause, re-occurrence is probable. RCAs are therefore necessary to ensure that problems are completely eradicated using long-term measures that would save time, effort and costs.

The Six Steps of Root Cause Analysis

Step 1: Gathering Information

The assigned team should first collect data regarding the incident to determine the chronology of the adverse event based on a factual account that is complete and accurate (CMS, 2018). This step begins with the establishment of an understanding amongst team members, which can be achieved through a flow chart of events. This will help in identifying the factual gaps in the events, systems and processes. There is no restrictive procedure used in the collection of data. Nonetheless, regardless the method of data collection, the tools used should illustrate a clear picture of what happened. This step is crucial to the entire process because it the foundation in which the team will draw conclusions (Ihi.org, 2018). The most prominent ways used to collect data include witness interviews, field observations, document and evidence reviews. Further, information gathered should be objective hence focus on identifying the processes and systems used rather than people involved during the event.

Step 2: Determine what should have happened

After determining what happened, the assigned team should create a flow chart that represents the appropriate way in which the situation should have been handled (CMS, 2018). To achieve this, the team needs to obtain a professional view on the processes and procedures used in a given scenario. The flow chart created in this step will be used to compare and identify the procedural gaps in the system used as illustrated by the first flow chart of events.

Step 3: Determine the Cause

In this step, the assigned team compares information gathered in the first step, with data gained in the second step to identify gaps which led to the undesired outcome (CMS, 2018). The team also reviews both direct and indirect factors which may include apparent and contributory factors respectively. To get adequate information, the RCA teams use the 5whys to identify the root cause of the problem.

Step 4: Develop causal statements

A casual statement is used to link the causes explained in step three to the outcome of an event (CMS, 2018). To develop an accurate causal statement, the team identifies the contributory factors gathered in step 3, then links them to their effects in the given situation and finally to outcome, which prompted the RCA.

Step 5: Generate a list of recommendations

This step forms the purpose of the RCA, which is to determine the best approach to rectifying the problem (CMS, 2018). The assigned team should therefore create a recommendations list that provides the action changes required to ensure the prevention of future errors. When conducting RCAs, recommendations are often confided within the following categories; promoting redundancy (counter checking systems to ensure accuracy), equipment standardization, using force functions aimed at physically preventing people from making mistakes, making updates to computerized systems, use of cognitive aids like labels, process simplification, staff training, development of new policies and change of physical plants (Ihi.org, 2018).

Step 6: Write Summary

In this stage, the assigned team writes a summary that reports their findings, conclusions and recommendation (CMS, 2018). This step is crucial and involves the collective effort of each member of the group to effectively clarify information, develop a flow chart that provides an accurate account of the events as well as offer probable solutions to the identified root cause of the problem.

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