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Guide to Performing a Root Cause Analysis (Revision …

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 .. 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: Create the Cause and Effect Diagram .. 15 Step 11: Craft the Final Understanding .. 19 Step 12: Identify and Craft root Cause and Contributing Factor Statements.

protected and deemed confidential under 38 U.S.C. 5705 and the implementing regulations (VHA Directive 2008-077, Quality Management (QM) and Patient Safety ... Once it is determined that an RCA is required for a reported safety event, the facility has 45 calendar days to complete the RCA, including obtaining ... they arise to guide the team’s ...

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www.patientsafety.va.gov

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

www.patientsafety.va.gov

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