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WGU C489 TASK 2: ROOT CAUSE ANALYSIS IN HEALTHCARE:
RCA STEPS & STRATEGIES
SAT1 — SAT TASK 2: RCA AND FMEA
Karina Lizotte
C489: Organizational Systems & Quality Leadership
Western Governors University
2/28/2026
, 2
A. Root Cause Analysis
A root cause analysis (RCA) is done to identify a problem, in healthcare this can be
something as severe as an adverse event, medical error or harm/death of a patient. There are a
few steps but essentially you want to analyze why the situation/problem happened (the root
cause) and try to find solutions to the problem. In healthcare this is done to create solutions and
ways to improve the system to prevent these problems from happening again.
A1. RCA Steps
The team for the RCA is usually 4-6 people from different professional backgrounds who
have knowledge of the incident, at all levels of the organization. There are six steps to most
RCA, according to the Institute for Healthcare Improvement (IHI).
The first step includes describing what happened as accurately and entirely as possible
and organizing all the information; a flowchart or diagram may be created to make the data
easier to follow by visually seeing what happened in chronological order (Patient Safety 104:
Root Cause and Systems Analysis Summary Sheet, n.d.).
The second step would be to conclude what should have happened in an ideal situation.
Again, a diagram or chart can be used to compare to the chart from the first step. (Patient Safety
104: Root Cause and Systems Analysis Summary Sheet, n.d.).
The third step is for the team to figure out the possible causes of the event. It is
recommended to ask the question “why?” five times to things that could have affected the
outcome indirectly, focusing on the most apparent and obvious. This is recommended in order to
obtain the root cause and in this step a cause-and-effect diagram may be helpful (Patient Safety
104: Root Cause and Systems Analysis Summary Sheet, n.d.).
WGU C489 TASK 2: ROOT CAUSE ANALYSIS IN HEALTHCARE:
RCA STEPS & STRATEGIES
SAT1 — SAT TASK 2: RCA AND FMEA
Karina Lizotte
C489: Organizational Systems & Quality Leadership
Western Governors University
2/28/2026
, 2
A. Root Cause Analysis
A root cause analysis (RCA) is done to identify a problem, in healthcare this can be
something as severe as an adverse event, medical error or harm/death of a patient. There are a
few steps but essentially you want to analyze why the situation/problem happened (the root
cause) and try to find solutions to the problem. In healthcare this is done to create solutions and
ways to improve the system to prevent these problems from happening again.
A1. RCA Steps
The team for the RCA is usually 4-6 people from different professional backgrounds who
have knowledge of the incident, at all levels of the organization. There are six steps to most
RCA, according to the Institute for Healthcare Improvement (IHI).
The first step includes describing what happened as accurately and entirely as possible
and organizing all the information; a flowchart or diagram may be created to make the data
easier to follow by visually seeing what happened in chronological order (Patient Safety 104:
Root Cause and Systems Analysis Summary Sheet, n.d.).
The second step would be to conclude what should have happened in an ideal situation.
Again, a diagram or chart can be used to compare to the chart from the first step. (Patient Safety
104: Root Cause and Systems Analysis Summary Sheet, n.d.).
The third step is for the team to figure out the possible causes of the event. It is
recommended to ask the question “why?” five times to things that could have affected the
outcome indirectly, focusing on the most apparent and obvious. This is recommended in order to
obtain the root cause and in this step a cause-and-effect diagram may be helpful (Patient Safety
104: Root Cause and Systems Analysis Summary Sheet, n.d.).
