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

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.