Annex 4 - compilation of approaches

Root cause analysis

Root cause analysis (RCA) is a class of problem solving methods, including fishbone diagrams, Pareto charts and scatter diagrams, aimed at identifying the root causes of a problem or event. It is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By identifying measures at the root cause, it is more probable that problem will not occur again.

The principle behind RCA is to take a systems approach to identifying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. Thus RCA identifies both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within healthcare systems that contribute to adverse events).

The approach generally begins with the collection of prescribed data and reconstruction of the event through record review and participant interviews. Within healthcare, a multi-disciplinary team would analyse the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why it occurred (through systematic identification and analysis of latent errors). RCA is typically used as a reactive method of identifying event causes, revealing problems and solving them, where analysis is done after the event has occurred. Its ultimate impact is typically dependent on spending sufficient time, effort and resources on risk control following the analysis.

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