Root Cause Analysis

• Where are the quality problems and which problems should I tackle first?
• Ishikawa / Fishbone / Cause & Effect Diagrams
• Process Mapping
• Five Whys
• Pareto Charts
• Failure Modes & Effects Analysis
• Root Cause Analysis

Root cause analysis (RCA) is defined as “an analytic tool that can be used to perform a comprehensive, system-based review of critical incidents.  It includes the identification of the root and contributing factors, determination of risk reduction strategies, and development of action plans along with measurement strategies to evaluate the effectiveness of the plans.”

RCA is part of a broader strategy for responding to and preventing critical incidents that includes:

• disclosure of harm to patients and their families
• communication of critical incidents to key individuals in the organization
• creation of a non-punitive culture which allows providers to openly disclose critical incidents
  

The steps involved in RCA include:

• creation of a team or committee to review the incident
• information gathering, including process mapping, interviews and a chronological log of events
• Exploration of root causes, RCA uses the same techniques described here (e.g. Ishikawa diagrams, 5 Whys, Failure Mode Effects Analysis, Pareto charts)
• Identification of ideas for preventing similar incidents in the future.
  
• Testing and implementing ideas for improvement. 
  

For more information, refer to the Canadian Root Cause Analysis Framework, published by the Canadian Patient Safety Institute, Saskatchewan Health and Institute for Safe Medication Practices Canada.