Nursing Resources

Root Cause Analysis (RCA) is a process for identifying the basic or contributing causal factors that underlie variations in performance associated with Adverse Events or Near Miss (Close Calls).  RCAs are conducted on Sentinel Events and other patient safety events.

A Sentinel Event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in the following:

• Death
• Severe harm (regardless of duration of harm). An event or condition that reaches the individual, resulting in life-threatening bodily injury (including pain or disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or a surgery, invasive procedure, or treatment to resolve the condition.
• Permanent harm (regardless of severity of harm): An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline.

See Sentinel Event Review Policy for full definition.

Apparent Cause Analysis (ACA) is a tool used to review an event when immediate interventions are necessary to prevent harm to patients and/or team members. 

• For ACAs impacting a patient, Risk Management or Quality and Patient Safety should be notified by phone when these ACAs are conducted (a call is not required for ACAs conducted on near misses).
• An ACA may be conducted for any safety event that might benefit from a multidisciplinary debrief (including near misses).

Root Cause Analysis has origins in science and engineering, as well as the quality movement in business.  So RCA's and related topics will show up in the literature on Lean, SixSigma, and business related sources, but is especially important in healthcare.  

From Harvard Business School Online:  Root Cause Analysis: What It Is and How to Perform One

From 6Sigma.us: How to Do Root Cause Analysis?  Everything you Need to Know

From IBM: What is a Root Cause Analysis?

From 6Sigma.us: Importance of Root Cause Analysis in Healthcare Industry

Forms and additional guidance can be found on the Quality & Patient Safety page on Insite: