Root Cause Analysis
RCA is a structured and process-focused way to analyse incidents without relapsing to “blaming and shaming”. Organizational factors can be identified, aknowledged and addressed, giving personnel the chance to suggest improvements of these factors. This way the personnel get a chance to learn from the adverse event and the organization can make effective changes to reduce the likelihood of future incidents. Thorough analysis of an adverse event also makes it easier to explain the chain of events to the involved patient or his/her family.
Experience in hospitals in the United States and Denmark gave reason to believe that using RCA not only produces significant results in understanding the cause of adverse events, but also contributes to a culture in which the emphasis rests on improvement of patient safety instead of on blame.
The information on this site about RCA has been presented at the Annual Conference of the European Association of Cognitive Ergonomics, 2005.