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Table 1 Process of root cause analysis (RCA)

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