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Root Cause Analysis (RCA) Process Steps.

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). Go back and forth between step 3 and step 4 if needed. step 5 synthesize information in final sequence of events. step 6 identify root- Cause and contributing factors.

Taking Action: Step 1 – identify actions implemented in similar past event(s). Step 2 – develop action plan. Step 3 – provide feedback to reporter. Step 4 – identify what was learned and who needs to know. Step 5 – create action plan for director, concur/non-concur. Step 6 – final sign-off RCA and action plan. Go to Final Step.

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