As its name would suggest, root cause analysis is the process by which teams of individuals assess and identify the underlying issues and factors 1 that lead to unintended outcomes.
In theory, root cause analysis is an investigative tool aimed at eliminating errors and improving the outcome of specific situations. If, for instance, treatment X results in unintended outcome Y, then one must merely identify and eliminate the root cause of errors in order to ensure the intended result.
Here is a simple illustration of root cause analysis, using a common tool known as the “5 Whys,” in which the question, “Why,” is asked five times to get to the originating cause of the problem. In this example, the “5 Whys” is applied to a flat tire.
1. Why did the tire go flat? Because I ran over a nail in the driveway?
2. Why was there a nail in the driveway? Because I failed to clean up the area after doing a home improvement project there.
3. Why did you fail to clean up the area? Because I didn’t allow adequate time for the project and had to leave for week.
4. Why did you not allow adequate time for the project? Because I had no idea it would take as long as it did.
5. Why did you not know how long the project would take? Because I had never done a project like this before.
The Relationship Between Events
Root cause analysis is based on the assumption that systems and events are interrelated. In other words, a specific action in one area triggers a specific action in another area, which triggers yet another specific action somewhere else. In the case of the flat tire example, the individual’s lack of experience in home improvement projects ultimately caused the flat tire. Had this person reached out for expert assistance prior to taking on the project, the flat tire could have been avoided.
The root cause of the flat tire was a human cause, which is one of three basic types of root causes. Human causes occur when people do something wrong or do not do something that is needed. Human causes usually lead to physical causes, which is the second basic type of root cause. A physical cause occurs when material items fail in some way, such as a tire going flat. The third type of root cause are organizational causes, which occur when a system, process, or policy that people use to make decisions or do their work is faulty.
Root cause analysis is a simple concept that relies on relatively simple tools, such as “5 Whys,” cause-and-effect diagrams, Pareto analysis, brainstorming, fault tree analysis, and more. When applied appropriately, these tools can be highly effective in uncovering employee issues, equipment problems, and system and process defects that cause adverse patient events to occur. So why hasn’t root cause analysis, then, led to broad-based improvements in patient safety?