Table 1

Main steps in root cause analysis (RCA)*

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.