The core of root cause analysis (RCA) is to properly identify the underlying problems of an issue. It is one of the most widely used retrospective methods for detecting issues. RCA uses a systematic approach to identify both active errors and latent errors which contribute to adverse events. RCA helps organizations avoid the tendency to single out one factor to arrive at the most expedient (but generally incomplete) resolution. It also helps to avoid treating symptoms rather than true, underlying problems that contribute to a problem or event. More often than not, we tend to assess blame and focus on just the mistakes made by individuals.
Most RCA experts believe that achievement of total prevention by a single intervention is not always possible, and see RCA as an ongoing process that strives for continuous improvement. It is not a one-size-fits-all methodology. There are many different tools, processes, and philosophies of accomplishing RCA. In fact, it was born out of a need to analyze various enterprise activities. RCA should follow a specified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should analyze the sequence of events leading to the error, with the goals of identifying how the event occurred.
The outcome of the root cause analysis is an action plan that the organization intends to implement in order to reduce the risk of similar events occurring in the future. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, timelines, and strategies for measuring the effectiveness of actions. Organizations can improve the efficiency and effectiveness of their operations through addressing the root issues of problems. For the purpose of an RCA, the focus should be on systems—how to improve systems to prevent the occurrence of events or problems. It involves digging into the organization’s systems to find new ways to do things.
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