Root Cause Analysis (RCA)

Root cause analysis (RCA) is an approach for post hoc analysis of an undesirable situation to determine what happened and, more importantly, why it happened. This makes it possible to identify strategies for preventing the situation from recurring. Thus RCA is a tool for identifying prevention strategies and continuous process improvement.

At the heart of RCA is the distinction between proximal and root causes. The proximal cause is the obvious cause. For example, suppose that a physician ordered medication that had a subsequent adverse effect on the patient. The proximal cause is human error by the physician. Knowing that the cause is human error, however, is not very useful in determining strategies for preventing this situation from recurring. More important to the development of prevention strategies is determination of the root cause or the cause that underlies the proximal cause. For example, the root cause of this situation could be that the physician had been working long hours and was not thinking clearly, that the physician had a cognitive impairment that should have been identified by credentialing activity, or that once the error had been made, the nurse didn't feel sufficient authority to question the medication order. Note that there are obvious strategies for dealing with each of these situations and preventing such a situation in the future, compared with trying to deal with the proximal cause of “human error.” This is typical of root causes; once the root cause is known, the solution is usually obvious.

RCA is typically conducted by an interdisciplinary team that includes knowledgeable individuals from all involved levels. Data analysis tools such as flowcharts, cause-and-effect diagrams, failure modes, and effects analysis and fault trees are used to analyze the evidence to separate proximal causes from the root cause. At the heart of these tools is asking “why” at each level of cause and effect to remove noncontributing causes. There are a number of commercially available software packages and consultants specializing in RCA training for health care organizations.

RCA is particularly important for health care organizations because of the September 1998 directive of the Joint Commission on Accreditation of Healthcare Organizations, the accrediting body used by the U.S. Department of Defense to validate military treatment facilities. This directive mandates that DOD facilities must comply with the sentinel event reporting process for identifying certain patient care events as potential markers of quality problems.

However, effective process improvement would move beyond mandated RCA of sentinel events to use it for a variety of adverse effects, from excessive waiting times for appointments and parking lot problems to surgical errors and increased suicide rates.

Once the root cause has been determined, it is critical to develop a set of recommendations for corrective action, including designating a person responsible for implementation of the corrective action and a reporting date. The plan should include a means for measuring the effectiveness of the changes. The corrective actions do not necessarily need to be designed to prevent the root cause from occurring. Rather, by understanding the entire logical chain of cause and effect, breaking the chain of events at any point will prevent the final failure from occurring.

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