Organizational Systems and Quality Leadership
Task 2
Ralph Spencer
Western Governors University
, C489 Task 2 (1217) 1
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI
The root cause analysis (RCA) is a standardized process to understand the cause of an
adverse event. A RCA is not a punitive or investigative step on an individual to place blame, but
more importantly it is designed to look at the process and determine where a mistake was made
and then determine how to decrease the chance that an adverse event occurs again. A RCA can
be created after a: near miss, incident report, medication error and customer or employee
complaint. The RCA team should be interdisciplinary and include all staff who would be
directly involved in the event.
The first step is to identify what happened, this description must be as accurate and
complete as possible. Sometimes a flowchart can be created in order to visualize the process.
This is the fact finding step of the process. Full understanding of how the error was performed,
by review of the medical record and incident report, is important in order to be accurate. The
data collection should not be performed by anyone involved in the error.
The second step is to determine what should have happened. Utilizing a flow chart with
the correct policy or procedure will aid in finding where the error or near miss occurred.
Comparing the actual sequence of events with internal policies and procedures and utilizing the
flow chart will show where variation has occurred in care.
The third step is to determine the cause. This is where you look at the direct as well as
the contributory causes that led to the error. A fishbone diagram can be useful during this step in
order to determine a cause and effect flow. Many RCAs recommend asking “Why” repeatedly in
order to find the exact issue that caused the problem.
The fourth step is to develop a causal statement that links the cause to the effect and then
the main event that caused the creation of the RCA. It's important to assign accountability for
Task 2
Ralph Spencer
Western Governors University
, C489 Task 2 (1217) 1
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI
The root cause analysis (RCA) is a standardized process to understand the cause of an
adverse event. A RCA is not a punitive or investigative step on an individual to place blame, but
more importantly it is designed to look at the process and determine where a mistake was made
and then determine how to decrease the chance that an adverse event occurs again. A RCA can
be created after a: near miss, incident report, medication error and customer or employee
complaint. The RCA team should be interdisciplinary and include all staff who would be
directly involved in the event.
The first step is to identify what happened, this description must be as accurate and
complete as possible. Sometimes a flowchart can be created in order to visualize the process.
This is the fact finding step of the process. Full understanding of how the error was performed,
by review of the medical record and incident report, is important in order to be accurate. The
data collection should not be performed by anyone involved in the error.
The second step is to determine what should have happened. Utilizing a flow chart with
the correct policy or procedure will aid in finding where the error or near miss occurred.
Comparing the actual sequence of events with internal policies and procedures and utilizing the
flow chart will show where variation has occurred in care.
The third step is to determine the cause. This is where you look at the direct as well as
the contributory causes that led to the error. A fishbone diagram can be useful during this step in
order to determine a cause and effect flow. Many RCAs recommend asking “Why” repeatedly in
order to find the exact issue that caused the problem.
The fourth step is to develop a causal statement that links the cause to the effect and then
the main event that caused the creation of the RCA. It's important to assign accountability for
