Guide to Performing a Root Cause Analysis (Revision 10-20 ...

1 Guide to Performing a Root Cause Analysis (Revision 10-20 -2020) 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 Diagram .. 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 .. 10 Step 5: Identify Information Gaps .. 11 Step 6: Use Triage Questions .. 11 Step 7: Collect Resources and Prepare for Interviews .. 12 Step 8: Conduct the Safety Investigation .. 12 Step 9: Create the Final Flow Diagram .. 13 Step 10: Craft the Final Understanding .. 15 Step 11: Create the Cause and Effect Diagram.

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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