Guide to Performing a Root Cause Analysis (Revision 02/05 ...

1 Guide to Performing a root Cause Analysis (Revision 02/05 /2021) Published by VHA National Center for Patient Safety (NCPS) 2 Table of Contents Introduction .. 4 Purpose of the guidebook .. 4 Determining when a root Cause Analysis is Required .. 5 Characteristics of a root Cause Analysis .. 5 root Cause Analysis Flow 6 Steps to Completing a root Cause Analysis .. 7 Step 1: Charter a Team .. 7 Step 2: Conduct Just in Time Training .. 8 Step 3: Create the Initial Flow Diagram .. 9 Step 4: Craft the Initial Understanding.

Program and VHA Patient Safety Handbook 1050.01. Intended users of this guidebook include patient safety managers or any persons who may lead, facilitate, or participate in RCAs. Definitions for key terms in the guidebook can be found in the Glossary (Appendix A). Upon review of the guidebook, the user will understand each step

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  Analysis, Review, Causes, Guidebook, Revisions, Root, Performing, Performing a root cause analysis, Revision 02

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