United States Department of Veterans Affairs

National Center for Patient Safety

Root Cause Analysis (RCA)
Note: Also see Rules of Causation and 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:

  1. Inter-disciplinary, involving experts from the frontline services
  2. Involving of those who are the most familiar with the situation
  3. Continually digging deeper by asking why, why, why at each level of cause and effect.
  4. A process that identifies changes that need to be made to systems
  5. A process that is as impartial as possible

To be thorough, a Root Cause Analysis must include:

  1. Determination of human & other factors
  2. Determination of related processes and systems
  3. Analysis of underlying cause and effect systems through a series of why questions
  4. Identification of risks & their potential contributions
  5. Determination of potential improvement in processes or systems

To be credible, a Root Cause Analysis must:

  1. Include participation by the leadership of the organization & those most closely involved in the processes & systems
  2. Be internally consistent
  3. Include consideration of relevant literature
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