Getting the Most out of Root-Cause Analyses

April 4, 2018 | Ambulatory Care Risk, Quality, & Safety Guidance

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Reactive analysis is a popular—and sometimes required—process intended to help organizations delve deeper into adverse events or near misses.

The process typically follows a preset structure and usually involves mapping of events, causal factors, and root causes. The method aims to identify and address deeper organizational issues (systems issues) that contribute to events in an attempt to prevent future events. The interactive Process for One RCA Model provides a brief outline of one approach to RCAs.

Different models offer different methodologies, tools, and steps and in some cases use different terms. For example, some models use the term "causal factors" to encompass factors that are not deep enough to be root causes, while other models use the term "proximal causes" or "contributory factors." Causal factors are sometimes further subcategorized into other concepts, such as direct causes, unsafe acts, unsafe conditions, or failures in barriers.

Unfortunately, many reactive analyses fail. Some limitations are inherent in studying an event retrospectively. First, many reactive analysis models are linear, which suggests direct causality. Difficulty in capturing the real complexity of systems and the myriad circumstances of events and conditions can bias investigators into believing that the factors identified are the only "causes" of an accident. In addition, the appearance of linearity can make it easy to fall into traps such as hindsight bias, and lead investigators to subjectively choose the events (including the initiating event) and conditions and, ultimately, the end or stopping point of the analysis. These limitations make the event look linear in retrospect; in reality, the circumstances did not appear linear to the people who were involved as the event unfolded.

In addition, investigators must be skilled and experienced in conducting investigations and performing such analyses; reactive analysis is not an undertaking that can be completed superficially, just by following a form. The investigation may also uncover lessons that span the organizations (e.g., device...

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