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Root Cause Analysis

Placing blame?

A classic analysis (written in 2001) outlines the complexities of individual accountability, disciplinary measures, and the idea of a blameless culture in healthcare.

Patient Safety and the "Just Culture": A Primer for Health Care Executives

Four key behaviors are examined from a healthcare perspective: human error, negligence, reckless conduct, and knowing violations.


"Root causes" are the fundamental reasons for the occurrence of a problem.

Root cause analysis (RCA) describes a wide range of approaches, tools, and techniques used to uncover the various contributing factors; there is almost never a single cause. The goal is not to find “the” correct representation of the problem and its causes. Instead, the goal is to find effective solutions that can be tested, then widely implemented, to prevent it from happening again.

A high level of effort and diligence is needed to eliminate any bias in the investigation. The team should be interdisciplinary and have leadership support.

Accidents happen!

  • Conducting an RCA can ensure the focus is on the process, not the people
  • An RCA can help determine the compensatory intervention and keep the project in scope


Keep these rules in mind as the RCA progresses:

  • Statements must show the cause-and-effect relationship
     
  • Negative descriptors are not to be used; instead use specific and accurate descriptors of what did happen
    • Avoid words like poorly, inadequately, improperly, carelessness
    • Example: Instead of “the nurse wasn’t paying attention,” write “the nurse didn’t hear the alarm.”
       
  • Each human error must have a preceding cause
    • Example:
      The aide did not accompany the resident to the toilet.
      -->caused by: The aide forgot.
      -->caused by: The aide was distracted by a phone call from a family member and was covering extra residents.
       
  • Each procedural deviation (or violation) must have a preceding cause
    • Example:
      The aide did not accompany the resident to the toilet.
      -->caused by: The aide decided not to do it.
      -->violation caused by: The aide had been caring for the resident for 3 weeks and felt that he sufficiently knew the resident's ambulatory abilities.
       

An Ishikawa or "fishbone" diagram can help RCA teams to organize and sort their ideas about problems as well as facilitate communication across the group. 
 

Additional Resources for Long-Term Care Facilities

For an overview of root cause analysis in the long-term care setting, see our 2013 recorded webinar (13 minutes).

For step-by-step assistance conducting a root cause analysis at your nursing home, consider using this step-by-step guide produced by the Oregon Patient Safety Commission and Oregon’s Patient Safety Improvement Corps.