Abstract

Root cause analysis (RCA) is a tool to help identify what, how, and why an event occurred so that steps can be taken to prevent future occurrences. Additionally, RCA may be used to target opportunities for systemwide improvement. Root causes are specific underlying causes that can be reasonably identified, are within management's control to remedy, and which generate effective recommendations to prevent recurrences. The RCA process involves data collecting, causal factor charting, root cause identification, and recommendation generation and implementation.