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Root Cause Analysis (RCA) Process Steps.

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VA National Center for Patient Safety RCA Step-By-Step Guide Page 1 root Cause Analysis (RCA) Process Steps. Getting Started: What happened? Why did it happen? What action can we take to prevent it from happening again? How will we know if the action we took made a difference? Step 1 charter/appoint RCA team. Step 2 Just in time training. Go to Analysis . Analysis : Step 1 Initial sequence of events. Step 2 identify information gaps (use triage questions). Step 3 Specify needed information (timeline and person responsible). Step 4 conduct fact-finding investigation (interviews, chart, literature reviews).

• Root causes/contributing factors define the team’s priorities about what must be fixed. • RC/CF identifies changes that could be made in systems and processes that would reduce the risk of the adverse event or close call recurring.

  System, Causes, Root, Root causes

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