Abstract

Although there are many tools available to conduct root cause analysis (RCA), the process is primarily cognitive. Someone must determine the cause of the problem before applying corrective action to prevent its recurrence. Some of the issues associated with RCA and how to overcome them are discussed. RCA has three major components: defining the problem, identifying the most likely cause, and collecting and analyzing data that points to or eliminates each of the identified causes. Human factors are important to effective RCA, as both individuals and groups exhibit emotional patterns that can support or detract from their ability to solve problems. Poor RCA makes it unlikely the right solutions will be identified and implemented. While organizational systems may cause the problems, only individuals can change things for the better. The online extension of this article presents excerpts and web links for five additional articles on root cause analysis techniques.