Page 1 Task #2 Melanie Troxell Western Governors University August 17, 2018
Page 2 A root cause analysis A root cause analysis… is a systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again. 1 There are six steps that IHI uses to conduct an RCA. 1. The first step is to identify what actually happened. In any event that requires a root cause analysis it’s likely that emotions are running high. It’s important to utilize information from any team members or witnesses to create an accurate picture of the event. 2. The next obvious step is that the team needs to “determine what should have happened.” There are likely already systems in place that aim for efficiency and safety. What would this story have looked like in an ideal situation? 3.Determine the causes. Some recommend that the group asks “Why?” five times. 4. It is then recommended that the group develop a list of “causal statements” to go along with these causes. This attempts to clarify cause and effect in the present context, for everyone. It also helps to organize the groups thoughts to help move forward in a plan.
Page 3 5. The next requirement is to come up with a list of recommended actions designed to prevent the event from recurring in the future. These recommendations are usually centered around creating or revamping systems and education, simplification and education. 6. The sixth step is to write a summary of all of the above to organize and visualize what happened so that all involved or all who might naturally be involved in a similar event in the future Application of the RCA process
- Fall '18
- Causality, Root cause analysis