Root Cause Analysis

Root Cause Analysis One of the more recent methods of investigating medical errors (MEs) and adverse reactions (ARs) is root cause analysis. Root cause analysis (RCA) is a systematic approach in investigating patient safety incidents by illuminating systemic problems and factors that contribute to MEs and ARs (Bowie, Skinner, & de Wet, 2013). The root cause of an incident is investigated using several analytical and problem-solving methods to uncover the detailed causes of a ME or AR (Bowie et al., 2013). The analysis team should be multidisciplinary so that identification of risk factor can be adequately evaluated and appraised (Giardina, King, Ignaczak, Paull, Hoeksema, Mills, Neily, Hemphill, & Singh, 2013). There are seven steps for RCA:
Formulate a plan to correct the causes,
7. Evaluate the plan (Bowie et al., 2013).
One technique in assuring that the root cause has been determined is utilizing the five why method. The method entails asking ‘why’ five times in order to establish the true root cause of an issue (Paulen, 2010). As a result of uncovering the root cause of an issue, the team can formulate recommendations to correct the organizational causes of the problem to diminish the issue from occurring again.

Figure 1. Illustration of the root analysis process adapted from 7 steps to 5 why by C. Paulsen, 2010, Lean Leadership website/

By using the RCA steps outlined above, there are a number of issues that can be attributed to the problems that occurred within the case study. In regards to the patient’s initial issue within the emergency room, there are two root causes of the patient not being seen in a timely manner. Since the patient’s primary language was not English, the staff member was limited in determining the severity of the patient’s abdominal pain. The staff member did not have the tools to effectively communicate with the patient. The other root cause, in this example, is the Figure 2. Root-cause analysis of case
Clinical risk management (CRM) is an essential component of identifying risks through clinical processes that directly and indirectly impact the patient and determining tools to augment safety (Briner, Kessler, Pfeiffer, Wehner, & Manser, 2010). “Systematic CRM integrates both proactive and reactive approaches and frames the hospital as a system, instead of focusing on individuals and their potential for committing errors” (Briner et al., 2010, p. 1). By focusing on the system, the CRM process develops policies, procedures, and tools to address high risks areas within the organization with the intention of managing risks within the clinical