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VHA National Center for Patient Safety

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Root Cause Analysis

We use a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls.

The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. Because our Culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function. We focus on the "how" and the "why" ? not on the "who". Through the application of Human Factors Engineering (HFE) approaches, we aim to support human performance.

Because people on the frontline are usually in the best position to identify issues and solutions, RCA teams at VA health care facilities formulate solutions, test, implement, and measure outcomes in order to improve patient safety.

The VA RCA Process

The goal of an RCA is to find out:

  • What happened
  • Why did it happen
  • How to prevent it from happening again.

The RCA process is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.

In an RCA, basic and contributing causes are discovered in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence.

The RCA process is: 

  • Inter-disciplinary, involving experts from the frontline services
  • Involving of those who are the most familiar with the situation
  • Continually digging deeper by asking why, why, why at each level of cause and effect.
  • A process that identifies changes that need to be made to systems
  • A process that is as impartial as possible

To be thorough an RCA must include: 

  • Determination of human and other factors
  • Determination of related processes and systems
  • Analysis of underlying cause and effect systems through a series of why questions
  • Identification of risks and their potential contributions
  • Determination of potential improvement in processes or systems

To be Credible an RCA must: 

  • Include participation by the leadership of the organization and those most closely involved in the processes and systems
  • Be internally consistent
  • Include consideration of relevant literature

Learn More

A detailed review of VA's RCA process:

The Patient Safety Improvement Handbook provides detailed information on how and why VA conducts RCAs, plus much more. VA patient safety reports, such as RCAs, are confidential under 38 U.S.C. 5705.

The Safety Assessment Code (SAC) can be used to determine whether or not an RCA must be conducted, based on the severity of a specific incident and its probability of occurrence.

A "SAC score" is also of value for incidents that did not result in an adverse event but may also lead to an RCA; i.e., a close call. Close calls occur far more frequently than adverse events and can provide an exceptional opportunity for learning. Close calls afford the chance to develop preventive strategies and actions before a patient may be harmed.

The SAC Matrix is a tool for combining severity and probablilty. While either the severity or probability of occurrence could be determined first, it is usually more productive to assess the severity first.

A wide range of related information is available by scrolling through our Glossary of Patient Safety Terms.

A number of articles have appeared in our newsletter, TIPS, which discuss the RCAs and the RCA process, such as:

  • May/June 2014: Staff Leadership Key to Enhancing the Root Cause Analysis Process: Root cause analysis team leaders and teams organized at the Charles George VA Medical Center, Asheville, N.C., include a diverse group of staff members, in an effort to promote the idea that patient safety is everyone’s concern.
  • May/June 2009: The Root Cause Analysis (RCA) Process, One Step at a Time: The article outlines each step in the RCA process on pages 1-3; and, provides web site references and related information on page 4

Published Articles

Numerous NCPS staff members, past and present, have coauthored articles that concern a wide of range of issues that involve RCAs.

  • Giardina, T.D., et al (2013). Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients. Health Affairs, 32(8), 1-8.
  • Percarpio, K.B., & Watts, B.V. (2013). A Cross-Sectional Study on the Relationship Between Utilization of Root Cause Analysis and Patient Safety at 139 Department of Veterans Affairs Medical Centers. Joint Commission Resources, 39(1), 35-40.
  • Lee, A., Mills, P.D., & Watts, B.V. (2012). Using Root Cause Analysis to Reduce Falls with Injury in the Psychiatric Unit. Hospital Psychiatry, 34(3), 304-11.
  • Lee, A, Mills P.D., and Neily J. (2012). Using Root Cause Analysis to Reduce Falls with Injury in Community Settings. Joint Commission Journal on Quality and Safety, 38(8), 366-374.
  • Mills, P.D., et al (2005). Using aggregate root cause analysis to reduce falls and related injuries. Joint Commission Journal on Quality and Safety, 31(1), 21-31.
  • Neily, J.B., et al (2003). Using aggregate root cause analysis to improve patient safety. Joint Commission Journal on Quality and Safety, 29(8), 434-439.
  • Bagian, J.P., et al. (2002). The Veterans Affairs Root Cause Analysis System in Action. Joint Commission Journal on Quality Improvement, 28(10), 531-545.