PS 201 Lesson 2: How a Root Cause Analysis Works
This lesson describes how to create an RCA team. It will walk you through the first four steps in an RCA, using a health care example to demonstrate how those steps fit together. You’ll learn whom to include on an RCA team, how to use a high-level flowchart to understand an event, and how to develop causal statements. Note: Because RCAs are usually conducted in teams, it may be beneficial to take this lesson with a small group.
Estimated Time of Completion: 30 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Describe the steps in a root cause analysis.
2. Construct useful statements about root causes.
3. Identify at least four types of factors that may contribute to error.
Contributors
Author(s):
Samuel Huber, MD, Associate CMO for Patient Safety and Quality, Rochester Regional Health System View Profile
Greg Ogrinc, MD, MS, Senior Associate Dean, White River Junction VA Medical Center View Profile
Editor(s):
Kathleen Vega, BA, Freelance Writer, Kathleen B. Vega, Inc View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Jo Inge Myhre, -, Head of Department, Department of Quality and Safety, Akershus University Hospital View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.