Root Cause Analysis

Root Cause Analysis (RCA) is a problem-solving tool that is most frequently used to determine the basic underlying factor(s) responsible for an event (ie, its root cause). This analysis is then used to determine the best method of preventing that event from occurring again.

A multitude of different RCA methods are available, but most of them have some basic principles in common. An RCA involves a systematic, data-driven, well-documented investigation into an event. It is a reactive method used to identify the steps in a system or process that are prone to failure, to determine the one or ones that failed and caused the event under investigation, and to determine how to prevent the failure from recurring. The RCA will also determine how many other factors were affected by the event under investigation.

The first step in an RCA is to clearly and factually describe the event or problem. Often the initial description of the problem will involve a timeline description of the proper process, the way the system SHOULD work, and then define the point or points at which the event under investigation differed from the proper course of events. Thus most RCA include a timeline, qualitative and quantitative data depicting the proper process and the failure steps, and thorough documentation of each step. Data is collected wherever necessary in order to be making decisions from data rather than from assumptions of how the system works. Once the root cause or causes of a problem have been clearly determined, an RCA again uses data to identify corrective actions to remedy anything that is wrong due to problem, as well as corrective actions to prevent the same problem from occurring in the future

Let’s pretend that patient test results were reported with the incorrect reference interval. In order to determine why this happened, we start by making a timeline depicting each step in the normal process. In our example, this means reviewing all the procedures in place for setting, maintaining, and changing reference intervals. Then, step by step, it can be determined where the process failed in this specific case, as well as other steps that might be prone to failure. Corrective actions to amend any incorrect patient results and notify caregivers would begin immediately, with thorough documentation. Once the root cause of the process failure is clearly identified and the step or steps that failed have been determined, additional corrective actions would be taken to remedy the necessary steps in the process so that this error cannot recur. Occasionally an RCA will lead to instituting an entirely new process in order to prevent problem recurrence. It’s important to note that everything associated with the RCA is fully documented.

Identifying and implementing solutions is probably the most important part of an RCA, yet it cannot occur effectively if the actual bottom-line cause of the problem has not been correctly identified in the first part of the process. If the root cause has not been correctly identified, the solutions become only a temporary patch on the problem, and the problem it will occur again. RCA generally involve time and work to do properly, and yet can be incredibly useful in preventing a recurrence. In a hospital or laboratory environment where potential patient harm can occur when a mistake it made, the RCA is often an important part of operating a healthcare system.

 

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

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