Root cause analysis (RCA) is a structured study that determines the underlying cause(s) of adverse or non-conforming events (NCEs) as well as "near misses." RCA focuses on systems, processes, and common causes that were involved in the adverse event. It then determines ways to prevent recurrence by identifying potential improvements in systems and processes that should decrease the likelihood of repeating the event.
Occurrences that may jeopardize patient safety must be investigated immediately, and appropriate risk-reduction activities must be implemented. (Always begin the investigation as soon as possible - don't wait - as evidence may disappear or persons involved may not have a good recall of the events after a long period of time has passed.)
However, root causes are often difficult to determine and are not always evident or apparent. It is easy to jump to conclusions and come up with a solution or solutions that do not really rectify the problem.
Some tools that are useful to start with are:
- Interviewing
- Looking at the process by using a flow chart, cause-and-effect diagram, and the “Five Whys” repetitive questioning technique
