Root Cause Analysis | Digital Healthcare Research

Examples

Latino RJ. The "5 PS" concept. Patient safety: the PROACT root cause analysis approach. Boca Raton, FL: CRC Press; 2009. p. 77-86.

Latino RJ. Case studies. Patient safety: the PROACT root cause analysis approach. Boca Raton, FL: CRC Press; 2009. p. 171-87.

Modaro C, Oyola T. Improvement of specimen courier system. 17th Annual Society for Health Systems Management Engineering Forum; 2005; Dallas, TX; 2005.

Description

Root cause analysis (RCA) is a popular technique used to determine why a problem occurred. The goal of a root cause analysis is to identify a problems origin by following a series of steps. This allows the analyst or analyzing team to identify the exact issue, identify the reason for the problems occurrence, and to develop means to prevent the issue from recurring or reduce the probability that it will happen again.

Uses

To determine the cause of an error.

How do I use this tool?

1. ASSEMBLE A TEAM OF PROCESS EXPERTS to study the event.

2. CREATE A FLOWCHART if necessary.

3. EXAMINE THE FLOWCHART for the failure.

4. USE GROUP TECHNIQUES to identify the underlying causes of the procedure at fault.

5. USE QUALITY IMPROVEMENT TOOLS to relate data to the identified root causes.

6. REDESIGN THE PROCESS as a group.

7. IMPLEMENT THE CHANGES. Pilot the changes with one small group before full-scale implementation, if possible.

Advantages

Identifies the underlying causes of problems.

Disadvantages

Assumes that systems and events are interrelated, which may not always be the case.

Where can I go to learn more?

Lighter D. Process orientation in health care quality. In: Moore C, editor. Quality management in health care: principles and methods. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2004. p. 43-101.

Kazandjian V. Root cause analysis and disclosure. In: O'Mara P, editor. Accountability through measurement: a global healthcare imperative. Milwaukee, WI: ASQ Quality Press; 2003. p. 99-109.