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What is an RCA?

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 27, 2006

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A root-cause analysis (RCA) is a process to help health care facilities and providers understand why a "sentinel event" occurred. Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). For example, a nurse getting stuck with a needle-even if he or she wasn't infected-could be a sentinel event because there was the risk of serious physical injury.

In conducting an RCA, hospitals try to answer the questions, "What led to this event taking place," and "what could our organization do to prevent such an event from occurring in the future?" It's a way of looking at the process within a system that broke down, thus allowing the adverse event to occur.

The process of an RCA is not to place blame on individuals involved in the sentinel event, but to analyze system issues that caused or contributed to the event and to prevent recurrence. RCAs are tools to help prevent future sentinel events from taking place.

Editor's note: The above excerpt is from the online course, "Patient Safety Series: A Step-by-Step Guide to Root-Cause Analysis." For more information on this and other courses in our library, go to www.hcprofessor.com.

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