Steps to
RCA
There are many potential routes to identify the event for analysis. Some examples include patient, staff, or physician incident reports, committee reports, or national reports.
Identify the event
STEP 1
Leadership establishes a project charter for the event and appoints a facilitator, who is well-versed in RCA techniques. The project should also identify an executive sponsor who is influential and accountable to the organization to ensure that the findings are implemented once completed.
Establish a charter
STEP 2
The facilitator begins with objective data collection and attempts to reconstruct the timeline of events; learning of the adverse event through detailed record review and participant interviews.
Reconstruct a timeline
STEP 3
A multidisciplinary team comprised of subject matter experts and selected direct participants analyze the sequence of events preceding the error to identify any contributory causes, including active errors and latent errors removed from direct patient contact. Techniques such as the 5 Whys and the fishbone diagram are best utilized during this process.
Analyze event sequence
STEP 4
Once you’ve identified the underlying process, systems issues, or root causes, the RCA group convenes to brainstorm solutions for the process and system issues. The group evaluates these solutions pre- and post-implementation.
Develop solutions
STEP 5
Once implemented, the facilitator collects the appropriate metrics for the solution to determine the overall success and reports the results. The goal of the RCA is identifying the root cause of an adverse event and developing an action plan to prevent or ameliorate an event’s recurrence.
Evaluate success
STEP 6
RCA Steps
Bonita
Created on August 28, 2024
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Transcript
Steps to
RCA
There are many potential routes to identify the event for analysis. Some examples include patient, staff, or physician incident reports, committee reports, or national reports.
Identify the event
STEP 1
Leadership establishes a project charter for the event and appoints a facilitator, who is well-versed in RCA techniques. The project should also identify an executive sponsor who is influential and accountable to the organization to ensure that the findings are implemented once completed.
Establish a charter
STEP 2
The facilitator begins with objective data collection and attempts to reconstruct the timeline of events; learning of the adverse event through detailed record review and participant interviews.
Reconstruct a timeline
STEP 3
A multidisciplinary team comprised of subject matter experts and selected direct participants analyze the sequence of events preceding the error to identify any contributory causes, including active errors and latent errors removed from direct patient contact. Techniques such as the 5 Whys and the fishbone diagram are best utilized during this process.
Analyze event sequence
STEP 4
Once you’ve identified the underlying process, systems issues, or root causes, the RCA group convenes to brainstorm solutions for the process and system issues. The group evaluates these solutions pre- and post-implementation.
Develop solutions
STEP 5
Once implemented, the facilitator collects the appropriate metrics for the solution to determine the overall success and reports the results. The goal of the RCA is identifying the root cause of an adverse event and developing an action plan to prevent or ameliorate an event’s recurrence.
Evaluate success
STEP 6