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Preserving evidence essential to effective RCAs
Quality Improvement Report, April 1, 2008
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A good root cause analysis (RCA) is akin to the investigations done on the hit television series “House.” You start off with a set of facts and drill down, using a cause-and-effect analysis, to discover what is truly making the patient sick.
“In the case of ‘House,’ it leads to a diagnosis,” says Gary Bonner, RN MBA, account manager at the Hopewell, VA–based Reliability Center, Inc., which provides hospitals with advice and software tools for conducting RCAs and Failure Modes and Effects Analyses (FMEA). “In the case of RCAs, it’s an acknowledgment of the root causes and the physical, human, and latent causes of that problem.”
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