1. 1 Root Cause Analysis

2. 2 - process for identifying the basic or causal factors that underlie variation in performance

3. 3 Root Cause Analysis - Focuses on systems, not people - Positive approach to system changes - Multidisciplinary - RCA can help identify risk-prone or weak points in processes

4. 4 Minimum Scope of RCA for Specific Types of Events –Key system issues: Staffing Training Communication Culture

5. 5 A Framework for a RCA and Action Plan What happened? Why did it happen What were the most proximate causes?

6. 6 Action Plan Identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future –Address implementation (who & when) –Measure ongoing effectiveness

7. 7 The purpose of Root Cause Analysis is to bring about SYSTEM CHANGES that will improve Patient Safety