Root cause analysis step | Process description |
Identify the event | Institutions should have in place a process for selecting which events undergo RCA |
Select team members | People with personal knowledge of the processes and systems involved in the event to be investigated |
Describe what happened | Collect facts surrounding the event to understand what happened |
Identify contributing factors | Identify circumstances that increased the likelihood of the event |
Identify root causes | Contributing factors are analysed to identify underlying process and system issues (root causes) of the event |
Design and implement changes to eliminate the root causes | Team determines how best to change processes and system to reduce likelihood of another similar event |
Measure success of changes | Success of implemented changes is measured |
* Adapted from: Guidance for Performing Root Cause Analysis https://www.cms.gov/medicare/provider-enrollment-and certification/qapi/downloads/guidanceforrca.pdf. Accessed 15 November 2016.