A classic analysis (written in 2001) outlines the complexities of individual accountability, disciplinary measures, and the idea of a blameless culture in healthcare.
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.
Keep these rules in mind as the RCA progresses:
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.
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.