Clinical Pathology: General Principles, Lab Management, Clinical Chemistry

• An root cause analysis (RCA) is a managerial tool that improves the quality of patient care by identifying errors that lead to an adverse event. It then seeks to define solutions.

• An RCA assumes that errors are best reduced by identifying and preventing the root cause(s) of an error.

• There are many methods and tools used in performing an RCA:

     • Methods: Event and causal factor mapping, tree diagrams, etc.

     • Tools: Ishikawa fishbone diagram, change analysis, Pareto analysis, etc.

• All methods for performing RCAs have limitations. For example, a Pareto analysis requires data to be collected to track the frequency of certain errors. If the database is inaccurate or incomplete, the RCA will not result in an appropriate solution.

• All RCAs share common characteristics regardless of the method or tools that are used:

     1. The adverse event or the problem is clearly identified.

     2. No blame is placed on a single individual or group because adverse events are usually due to a chain of errors.

     3. Specific causes and effects are identified; typically identifies a system of errors rather than a single cause.

     4. These causes and effects are supported by evidence.

     5. Results in a clearly defined, executable, quantifiable solution(s) that can be monitored quantitatively.

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