141st APHA Annual Meeting and Exposition

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Recorded Annual Meeting Presentations (RAMP) are now available for purchase.
Only $90 for presenters, $140 for registered attendees and $200 for non-attendees.

Online Program

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What is root cause analysis and when and how do I use it?


Wednesday, November 6, 2013 : 12:30 p.m. - 12:45 p.m.

Lou DiBerardinis, CIH, CSP, Department of Environment, Health and Safety, Massachusetts Institute of Technology, Cambridge, MA
Ruth Fishbein, MA, MSW, CPHQ, Medical Department, Massachusetts Institute of technology, Cambridge, MA
     
Root Cause Analysis (RCA) is a structured approach to indentifying the factors that resulted in the nature, magnitude, location and timing of the harmful or negative or positive outcome of a past event or sequence of events in order to identify what behaviors, actions, inactions or conditions need to be changed to prevent reoccurrence of similar harmful outcomes and to identify the lessons to be learned and shared to promote the achievement of better future consequences.

Most of the time Public Health professionals do not have the time to perform an adequate RCA. An adverse event occurs, we respond to it and solve the immediate problem and then move on to the next one. We identify the immediate cause and correct it. Rarely do we dig deep enough to identify the underlying causes. This is a missed opportunity to learn from the event and more importantly reduce the liklihood for a similar incident to occur.

This presentation will discuss how to develop a successful RCA program. This includes an understanding of what a RCA is, determining when to perform one, selecting the right tool to use, establishing the process to follow, creating an environment and culture that encourages open discussion of such incidents and identifying ways to share the lessons learned with the entire organization.

Learning Areas:

Occupational health and safety

Learning Objectives:
Define Root Cause Analysis (RCA) Identify when to use RCA Describe an example process flow for performing a RCA Discuss Tools that could be used in a RCA

Keyword(s): Managing Risks, Injury Prevention

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: As the Director of Performance Improvement and Risk Management at MIT's Medical Department I have been training staff and facilitating RCA projects as part of the department's patient safety/risk managment program. I also have been consulting to the MIT's Root Cause Analysis Workgroup and am a member of MIT's Risk Council.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 5187.0: Root Cause Analysis as a Tool for Prevention