Root Cause Analysis (RCA)
Note: Also see Rules of Causation
Triggering and Triage Questions
For information about ordering printed Triage Cards, please see Frequently Asked Questions
The goal of a Root Cause Analysis
is to find out
- What happened
- Why did it happen
- What to do to prevent it from happening again.
Root Cause Analysis is a tool for identifying prevention strategies. It is a process that is part of
the effort to build a culture of safety and move beyond the culture of blame.
In Root Cause Analysis, basic and contributing causes are discovered
in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence.
Root Cause Analysis is:
- Inter-disciplinary, involving experts from the frontline services
- Involving of those who are the most familiar with the situation
- Continually digging deeper by asking why, why, why at each level of cause and effect.
- A process that identifies changes that need to be made to systems
- A process that is as impartial as possible
To be thorough, a Root Cause Analysis must include:
- Determination of human & other factors
- Determination of related processes and systems
- Analysis of underlying cause and effect systems through a series of why questions
- Identification of risks & their potential contributions
- Determination of potential improvement in processes or systems
To be credible, a Root Cause Analysis must:
- Include participation by the leadership of the organization & those most closely involved in the processes & systems
- Be internally consistent
- Include consideration of relevant literature