Diagnosis:
Root cause analysis
• 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.
