1
Running head: C489 TASK TWO
Task 2 C489
Tammy Cosby
Western Governors University
December 20, 2018
,2
Running head: C489 TASK TWO
A:
Root Cause Analysis
To explain the general purpose for conducting a root cause analysis (RCA), one must first
understand what a root cause is. Two Medical Doctors by the name of Ogrinc & Huber (2010)
state, “A root cause is a latent vulnerability in a system that allows an error to occur; changing or
correcting the root cause could help prevent the error from happening again” (p.4). RCA is a
systemic approach, meaning the use of the most efficient means to generate optimum results.
Therefore, a root cause analysis helps one to understand the cause of an error by looking at the
flaws that can be corrected with hopes to prevent the error from happening again.
A1:
RCA Steps
Although each RCA has its own unique situation, there are six steps that are generally
used to conduct an RCA and are listed below. These steps are conducted by a team of at least
four individuals with various involvement with the incident.
Step 1: Identify what happened by gathering information.
A description of what happened needs to be as accurate and thorough as possible with the
ultimate goal of improvement being at the forefront. The RCA team can gather this information
by examining areas involved in the event, conducting interviews with staff or family members
involved and reviewing incident reports that might have come from the event. Identifying what
happened rather than why it happened is essential for honesty and trust from those being
interviewed. Neutral, open-ended questions should be asked during this step which allows for a
blame free process. Flowcharts are a good tool used in this step and allows one to look at the
, 3
Running head: C489 TASK TWO
incident methodically and review the steps for any particular situation in an unbiased manner
(Ogrinc & Huber, 2010, p 7-8).
Step 2: Determine what should have happened.
Step two in the RCA process focuses on what would have happened if everything would have
gone perfectly and a good outcome was maintained. Hospital policies and procedures could be
analyzed, sifting through medical literature and interviewing department directors are tools that
can be used to find out barriers to safe practice. Another flowchart is created showing what
should have occurred if compliable procedures would have been followed. The flowchart are
then compared to see what the ideal process is and the process that led to the adverse event to
narrow down contributing factors later in the process (Ogrinc & Huber, 2010, p. 9).
Step 3: Determine causes.
This step is at the heart of the RCA process. In this step factors that led to the event are
determined and improvement projects and strategies are put into place. Direct causes and
contributory factors are identified in this step. Direct causes are the most apparent or immediate
reason for the adverse event, whereas contributory factors are more indirect and are the ones that
need focus. Determining the causes or contributing factors is different for each case. However,
in general the RCA teams will need to ask questions. Particularly why questions need to be
asked and asked a lot. Typically, why questions need to be asked up to five times if not more.
This can help the team avoid quick solutions that may pop up again later if not handled properly.
After the facts are obtained it is helpful to organize the factors that led to the adverse event into
groups. This can be done with a fishbone diagram which shows the cause and effect of a
particular incident. This diagram looks like the scale of a fish with the spine being the unwanted
outcome, the ribs are the categories and the small bones are the contributory factors falling into
Running head: C489 TASK TWO
Task 2 C489
Tammy Cosby
Western Governors University
December 20, 2018
,2
Running head: C489 TASK TWO
A:
Root Cause Analysis
To explain the general purpose for conducting a root cause analysis (RCA), one must first
understand what a root cause is. Two Medical Doctors by the name of Ogrinc & Huber (2010)
state, “A root cause is a latent vulnerability in a system that allows an error to occur; changing or
correcting the root cause could help prevent the error from happening again” (p.4). RCA is a
systemic approach, meaning the use of the most efficient means to generate optimum results.
Therefore, a root cause analysis helps one to understand the cause of an error by looking at the
flaws that can be corrected with hopes to prevent the error from happening again.
A1:
RCA Steps
Although each RCA has its own unique situation, there are six steps that are generally
used to conduct an RCA and are listed below. These steps are conducted by a team of at least
four individuals with various involvement with the incident.
Step 1: Identify what happened by gathering information.
A description of what happened needs to be as accurate and thorough as possible with the
ultimate goal of improvement being at the forefront. The RCA team can gather this information
by examining areas involved in the event, conducting interviews with staff or family members
involved and reviewing incident reports that might have come from the event. Identifying what
happened rather than why it happened is essential for honesty and trust from those being
interviewed. Neutral, open-ended questions should be asked during this step which allows for a
blame free process. Flowcharts are a good tool used in this step and allows one to look at the
, 3
Running head: C489 TASK TWO
incident methodically and review the steps for any particular situation in an unbiased manner
(Ogrinc & Huber, 2010, p 7-8).
Step 2: Determine what should have happened.
Step two in the RCA process focuses on what would have happened if everything would have
gone perfectly and a good outcome was maintained. Hospital policies and procedures could be
analyzed, sifting through medical literature and interviewing department directors are tools that
can be used to find out barriers to safe practice. Another flowchart is created showing what
should have occurred if compliable procedures would have been followed. The flowchart are
then compared to see what the ideal process is and the process that led to the adverse event to
narrow down contributing factors later in the process (Ogrinc & Huber, 2010, p. 9).
Step 3: Determine causes.
This step is at the heart of the RCA process. In this step factors that led to the event are
determined and improvement projects and strategies are put into place. Direct causes and
contributory factors are identified in this step. Direct causes are the most apparent or immediate
reason for the adverse event, whereas contributory factors are more indirect and are the ones that
need focus. Determining the causes or contributing factors is different for each case. However,
in general the RCA teams will need to ask questions. Particularly why questions need to be
asked and asked a lot. Typically, why questions need to be asked up to five times if not more.
This can help the team avoid quick solutions that may pop up again later if not handled properly.
After the facts are obtained it is helpful to organize the factors that led to the adverse event into
groups. This can be done with a fishbone diagram which shows the cause and effect of a
particular incident. This diagram looks like the scale of a fish with the spine being the unwanted
outcome, the ribs are the categories and the small bones are the contributory factors falling into
