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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. Go to Taking Action. Taking Action: Step 1 identify actions implemented in similar past event(s).

Root Cause Analysis (RCA) Step-By-Step Guide RCA is a process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or close calls. An RCA is a specific type of focused review that is used for all patient safety adverse events or close calls requiring analysis.

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