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Root Cause Analysis: Exploring What Happened, Why, and How to Fix It

Root cause analysis (RCA) is a common tool that has been used in the business world for many years but has only recently been applied in health care. As concerns over quality patient care and medical malpractice have multiplied, methods for addressing medical errors such as RCA have become increasingly important. According to the Department of Veterans Affairs National Center for Patient Safety, RCA is "a process that is part of the effort to build a culture of safety and move beyond the culture of blame… [the process is] similar to diagnosis of a disease—with the goal always in mind of preventing reoccurrence." Rather than continually dealing with the repercussions of a mistake, RCA uncovers the cause of the problem and offers suggestions on ways to prevent the mistake from occurring again. In RCA, three questions are asked: what happened; why did it happen; and what can be done to prevent it from happening again?

Once a problem has been identified, the RCA process begins with the assembly of an investigation team that includes the leadership of an organization and individuals with expertise in the areas in which the problem occurred. The team should:
  • Collect data. They must interview personnel regarding what happened and study evidence.
  • Brainstorm about the potential causes of the problem. The team must consider three different types of causes:
    • Direct causes: those causes that directly resulted in the problem occurring.
    • Contributing causes: causes that indirectly influenced the outcome.
    • Root cause: the cause that, if corrected, would stop the causal factor chain and prevent the problem from occurring.
  • Create a chronological flow chart working backwards from the mistake. By continually asking “why?” the team can create the timeline of events that led to the error.
  • Consider human involvement in the mistake, but look beyond it to uncover the reason behind human error. According to the website www.systemsthinking.org, which provides an overview of RCA, research has shown that 95 percent of errors within organizations pertain to process and only five percent are related to individuals. Many RCA teams originally identify individuals as the root cause of a problem and often need assistance in refocusing their investigation.
  • Brainstorm ways to resolve the issue by considering improvements to organizational processes or systems.
  • Decide whether it is more cost-effective to resolve the root cause and stop the mistake from occurring again or to continually deal with the mistake when it reoccurs. Monetary costs and consumer satisfaction should be taken into consideration.

Known as the “Five Whys” method of RCA, the following is an example from the Institute of Healthcare Improvement of how to work backwards to uncover the root cause.
  1. Why is a patient’s intravenous run rate wrong?
    The previous nurse didn’t change the run rate.
  2. Why didn’t the previous nurse change the rate?
    The doctor’s order had gone to the pharmacy and the medication administration record (MAR) was not updated.
  3. Why wasn’t the MAR updated?
    The MAR is updated only once per day.
  4. Why is the MAR updated only once per day?
    The hospital has chosen to use oral instructions for updates that happen more frequently.
  5. Why are oral instructions used?
    The process was constructed a decade ago, when medication orders changed less frequently due to longer lengths of stay. Upon further study, the hospital determines that 40 to 50 percent of its medications change every day."

Another way to construct an RCA is to develop a fishbone diagram (Figure). This diagram, created by Kauro Ishikawa of Tokyo University in 1943, is also known as a cause and effect diagram. There are numerous computer software tools available that can assist in utilizing root cause analysis (for example, PROACT® RCA Software and REASON® Root Cause Analysis) as well as “how-to” books such as “The Root Cause Analysis Handbook” by Max Ammerman and Root Cause Analysis: Basic Tools and Techniques by Denise Robitaille. Mention of these products does not imply their endorsement by the Alliance for Academic Internal Medicine (AAIM).

For more information about RCA, please contact AAIM Policy Assistant Allison Haupt at (202) 861-9351 or ahaupt@im.org.