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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