From: How to perform a root cause analysis for workup and future prevention of medical errors: a review
Step 1: Identify Adverse Event • Honest and open reporting of adverse events • Committee review of clinical documentation to understand basics of what event happened? When? Who was involved? How and why did it happen? • Identify appropriate RCA investigations |
Step 2: Organize a Team • Team should consist of 4–6 members of clinicians, supervisors, quality improvement experts with fundamental knowledge of specific area of interest • Ensure that despite members having different levels of authority, everyone should be treated as equals • Members should not be directly involved with the case in question • Appoint an unbiased team leader/facilitator |
Step 3: Develop an Initial Flow Diagram • Use a flowchart to describe the processes leading to the event • Organizing the information to reach a mutual understanding of the problem |
Step 4: Develop an Event Story Map • Use of Triggering questions to guide further investigation • Conduct thorough interviews with all parties involved in event • Thorough review of clinical documentation surrounding the event |
Step 5: Develop a Cause and Effect Diagram • Identify a single problem statement • Identify Actions and Conditions that caused the problem statement • These categories should address communication problems, policies, rules, procedures and human errors leading to the event |
Step 6: Identify Root Cause Contributing Factors (RCCF) • Describe how a cause led to an effect and increased the likelihood of adverse event • Apply 5 rules of causation for crafting RCCF statements |
Step 7: Develop Corrective Actions • Identify barriers and risk reduction strategies to prevent root cause from recurring • Multiple actions may be required • Implement a trial test of corrective action |
Step 8: Measure Outcomes • Develop outcome measurements to ensure appropriate implementation of actions • Track quantifiable data to document effectiveness of actions over time • Evaluate and fine-tune improvement efforts if needed |
Step 9: Communicate Results • Communicate results of RCA to all staff involved in event and more broadly if applicable |