Root Cause Analysis: What You Need to Know

Root Cause Analysis (RCA) is a foundational patient safety tool tested on the CPHQ exam. You must understand when to conduct an RCA, how to perform one, and what actions should follow.

When to Conduct an RCA

An RCA is required after sentinel events and recommended after serious adverse events. The Joint Commission requires accredited organizations to conduct a thorough and credible RCA for every sentinel event. An RCA should be completed within 45 days of the event.

The RCA Process

Form a multidisciplinary team that includes people involved in the process but not necessarily those involved in the specific event. Gather data through chart review, interviews, timeline reconstruction, and observation. Use cause-and-effect diagrams, the "5 Whys" technique, and process mapping to identify contributing factors at the system level.

Systems Focus

The most important principle for the CPHQ exam: RCA focuses on systems and processes, not individuals. The goal is to identify system failures that allowed the event to occur, not to assign blame. Questions that present individual-focused responses versus system-focused responses will almost always have the system-focused answer as correct.

Action Plans

The RCA must result in specific, measurable corrective actions. Strong actions include physical changes, forcing functions, and standardization. Weak actions include training, policy changes, and increased vigilance. The exam frequently tests this hierarchy of action strength.