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Western Governors University C489 Organizational
Systems and Quality Leadership | SAT Task 2
, 2
A root cause analysis is a systematic approach used to determine and understand the
cause of an event and help to recognize the flaws that led up to the said event. A root cause
analysis (RCA) helps to identify the mistakes that occurred in the system that led to the event
and then identifies what needs to be changed in order to prevent this situation from happening
again. An RCA focuses on the cause of the event rather than placing blame on an individual or
individuals; it looks at the system as a whole because accidents almost never stem from a single
cause but from a mixture of several contributory factors, such as work conditions or latent
failures. (IHI: Patient Safety, n.d.)
According to the Institute of Healthcare Improvement (IHI) there are 6 steps involved in
an RCA. Step one is to identify what occurred by gathering accurate and complete information.
Step two is to determine what should have transpired in idyllic conditions. Step three is to
determine the issues that led to the event by looking at the direct causes and other contributing
factors. Step four is to develop a causal statement that shows the relationship between the cause
and effect and then connect it back to the main incident that incited the RCA to begin with. Step
five create a list of suggested actions that will prevent a repeat of the event from reoccurring. The
sixth and final step of the RCA process is to write a summary and share it with all those that will
help to implement the improvement steps in order to prevent another event from happening.
(IHI: Patient Safety, n.d.)
Using the steps of the RCA process to identify causative and contributing factors include
Step 1: Mr. B died after receiving large amounts of sedatives he received for a hip dislocation
that Dr. T prescribed to assist in the manipulation, relocation and alignment of Mr. B’s hip. Mr. B
Western Governors University C489 Organizational
Systems and Quality Leadership | SAT Task 2
, 2
A root cause analysis is a systematic approach used to determine and understand the
cause of an event and help to recognize the flaws that led up to the said event. A root cause
analysis (RCA) helps to identify the mistakes that occurred in the system that led to the event
and then identifies what needs to be changed in order to prevent this situation from happening
again. An RCA focuses on the cause of the event rather than placing blame on an individual or
individuals; it looks at the system as a whole because accidents almost never stem from a single
cause but from a mixture of several contributory factors, such as work conditions or latent
failures. (IHI: Patient Safety, n.d.)
According to the Institute of Healthcare Improvement (IHI) there are 6 steps involved in
an RCA. Step one is to identify what occurred by gathering accurate and complete information.
Step two is to determine what should have transpired in idyllic conditions. Step three is to
determine the issues that led to the event by looking at the direct causes and other contributing
factors. Step four is to develop a causal statement that shows the relationship between the cause
and effect and then connect it back to the main incident that incited the RCA to begin with. Step
five create a list of suggested actions that will prevent a repeat of the event from reoccurring. The
sixth and final step of the RCA process is to write a summary and share it with all those that will
help to implement the improvement steps in order to prevent another event from happening.
(IHI: Patient Safety, n.d.)
Using the steps of the RCA process to identify causative and contributing factors include
Step 1: Mr. B died after receiving large amounts of sedatives he received for a hip dislocation
that Dr. T prescribed to assist in the manipulation, relocation and alignment of Mr. B’s hip. Mr. B
