Root Cause Analysis (RCA):
A structured process for identifying the causal or contributing factors underlying adverse events or other critical incidents.(1,2) The key advantage of RCA over traditional clinical case reviews is that it follows a pre-defined protocol for identifying specific contributing factors in various causal categories (eg, personnel, training, equipment, protocols, scheduling) rather than attributing the incident to the first error one finds or to preconceived notions investigators might have about the case. For instance, in a case involving a patient who mistakenly received someone else’s invasive cardiac procedure,(3) the initial reaction of many hearing about the case might be: the nurse should have checked the wrist band. Or, how could the doctor not have looked at the face of the patient on the operating table? Traditionally, an internal review of such a case would do little more than reiterate these "first stories"(4)—typically involving errors committed by personnel at the "sharp end"—and miss the "second stories" that emerge from more detailed, open-minded investigation.
Though the definition of RCA emphasizes analysis, the single most important product of an RCA is descriptive—a detailed account of the events that led up to the incident. For instance, in the case mentioned above,(3) the detailed catalogue of events leading up to the "wrong person procedure" included 17 distinct errors, rather than one or two "so-and-so should have checked such-and-such" errors.
Root cause analysis is still a widely used term, but many now find it misleading. Critics of the term argue that there are no true "causes," so much as "contributing factors." This is not entirely a semantic distinction. As illustrated by the Swiss cheese model, multiple errors and system flaws must come together for a critical incident to reach the patient. Labeling one or even several of these factors as "causes" fosters undue emphasis on specific "holes in the cheese" rather than the overall relationships between different layers and other aspects of system design. Accordingly, some have suggested replacing the term "root cause analysis" with "systems analysis."(5)
Specific resources that facilitate carrying out RCAs or "systems analyses" can be found at:
Root Cause Analysis (RCA). Veterans Affairs National Center for Patient Safety Web site.
Available at: http://www.patientsafety.gov/rca.html.
Taylor-Adams S, Vincent C. Systems analysis of critical incidents: the London Protocol. London, UK: Clinical Safety Research Unit, Imperial College London; 2004.
Available at: http://www.csru.org.uk/downloads/SACI.pdf.
1. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058; 2001.
Available at: http://www.ahrq.gov/clinic/ptsafety/chap5.htm
2. Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002;28:531-545.
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3. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826-833.
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4. Cook RI, Woods DD, Miller C. A Tale of Two Stories: Contrasting Views of Patient Safety. National Patient Safety Foundation at the AMA: Annenberg Center for Health Sciences, Rancho Mirage, CA; 1998.
Available at: http://www.npsf.org/exec/front.html.
5. Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care. 2004;13:242-243.
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