Root Cause Analysis in Healthcare
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. Thus it can be said that Root Cause Analysis is inter
disciplinary, involving experts from the frontline services, involving 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 and a process that is as impartial as possible. The goal of a
Root Cause Analysis is to find out what happened, why did it happen and what do you do to prevent it from
happening again. 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. To be thorough, a Root Cause
Analysis must include determination of human and other factors, determination of related processes and
systems and analysis of underlying cause and effect systems through a series of why questions like
identification of risks and their potential contributions and determination of potential improvement in processes
or systems. To be credible a Root Cause Analysis must include participation by the leadership of the
organization and those most closely involved in the processes and systems. It should also be internally
consistent and include consideration of relevant literature.
