Root Cause Analysis (RCA) is a technique used to identify the underlying cause of a problem or issue. It goes beyond surface-level symptoms and aims to uncover the root cause, which is often different from what initially appears to be the problem. By understanding the true cause, organisations can develop effective solutions to prevent similar issues from occurring in the future.
Healthcare systems are complex, and Root Cause Analysis works best for exploring simple issues. For more complex issues and to explore using a systems approach we recommend SEIPS (System Engineering Imitative for Patient Safety). Find out more about SEIPS.
How do you do a Root-Cause Analysis?
The process of Root Cause Analysis involves a systematic approach to investigating the problem and identifying the factors that contributed to its occurrence. Here are the steps involved:
- Define the Problem: Clearly articulate the problem and its specific symptoms. This provides a clear starting point for the analysis.
- Collect Data: Gather relevant data and evidence that support the existence and impact of the problem. Consider the duration of the problem and its overall consequences.
- Identify Possible Causal Factors: Identify the sequence of events and conditions that led to the problem. Look beyond the immediate causes and consider any other problems associated with the central issue.
- Identify the Root Cause(s): Dig deeper to understand why the causal factors exist. Uncover the underlying reasons behind the problem, using tools and techniques to analsze each level of cause and effect.
- Recommend and Implement Solutions: Based on the analysis, develop recommendations to address the root cause(s) and prevent the problem from recurring. Consider the implementation plan, assign responsibilities, and assess potential risks.
Root Cause Analysis is a valuable tool for problem-solving and decision-making in various fields, including healthcare, engineering, and business. It provides a structured and systematic approach to uncovering the root cause of problems, leading to more effective and sustainable solutions.
RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, it is possible to discover where the problem started and how it grew into the symptom now being faced.
There are usually find three basic types of causes:
- Physical causes – Tangible, material items failed in some way (for example, a car’s brakes stopped working).
- Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
- Organisational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).
Implementing Root Cause Analysis requires collaboration and input from various stakeholders. By involving experts and frontline staff who have firsthand knowledge of the problem, organisations can gather diverse perspectives and insights that contribute to a more robust analysis.