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VHA National Center for Patient Safety


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Root Cause Analysis

Conducting a Root Cause Analysis (RCA) is a critical aspect in the process of improving patient safety. Multidisciplinary RCA teams investigate matters ranging from medication errors, to suicides, to wrong site surgeries. The goal of the RCA process is to find out what happened, why it happened, and to determine what can be done to prevent it from happening again. Clinicians meeting across a table to discuss various issues. 

The teams investigate adverse events and close calls. Close calls are events that could have resulted in a patient’s accident or injury, but didn’t  — either by chance or timely intervention.

RCAs are used to focus on improving and redesigning systems and processes — rather than focus on individual performance, which is seldom the sole reason for an adverse event or close call. A previously unheeded or unnoticed chain of events most often leads to a recurring safety problem, regardless of the personnel involved.

Because people on the frontline are usually in the best position to identify issues and solutions, RCA teams at VA health care facilities include a cross section of VA employees.

VA teams improve patient safety at their facilities by formulating solutions, testing, implementing, and measuring outcomes. To be truly effective, however, the RCA process must include support by the organization’s leadership. This can range from chartering an RCA team, to direct participation on a team, to participation in designing a corrective action plan.

Findings can be shared nationally if there is a clear benefit for multiple facilities. These findings are categorized by NCPS. To ensure that the findings are focused on systems improvement, before dissemination, all personal and facility names, facility locations, and other potentially identifying information have been removed.

NCPS offers RCA training at locations around the nation on a regular basis, and includes interactive exercises. Training includes an introduction to a software system developed by NCPS, the Patient Safety Information System — an internal, confidential, non-punitive reporting system that supports the RCA process.

NCPS has also developed cognitive aids that were created for use as detailed reference materials for team members and students alike. These include:

Teams use these aids to develop such things as a chronological event flow diagram and a cause and effect diagram:

  • A chronological event flow diagram provides each team member with the same initial understanding of what occurred, helping to avoid differing interpretations of the same event.
  • A cause and effect diagram helps teams progress logically from what happened to why it happened.

Learn More

RCA Overview