The Effectiveness of Root Cause Analysis: What Does the Literature Tell Us?

Authors: Percarpio, Katherine B.; Watts, B. Vince; Weeks, William B.

Source: Joint Commission Journal on Quality and Patient Safety, Volume 34, Number 7, July 2008 , pp. 391-398(8)

Publisher: Joint Commission Resources

Buy & download fulltext article:

Price: $20.00 plus tax (Refund Policy)

Abstract:

Background: Root cause analysis (RCA) is an analysis framework used in health care to determine the systemic causes and prevent recurrences of adverse events. It is required by The Joint Commission for reported events and by the Department of Veterans Affairs (VA) National Center for Patient Safety for qualifying events in VA medical centers. The evidence on RCA effectiveness in improving patient safety was reviewed.

Methods: MEDLINE^®, Academic Search^™ Premier, and the Cochrane Database were searched from database inception to September 2007. RCA case studies and articles that directly addressed the RCA framework were reviewed.

Results: Discussion of RCA did not emerge in the literature until the late 1990s, and there have been no controlled trials that test the RCA framework. Twenty-three articles describe the RCA process, 38 articles present RCA case studies, and 12 articles analyze weaknesses of the RCA framework. Eleven of the case studies measure RCA effectiveness, 3 using clinical outcome measures and 8 using process measures. All 11 articles report improvement of safety following RCA. RCA participants report the difficulty in forming causal statements and in developing/implementing corrective actions. Criticisms of RCA include the uncontrolled study design and participant biases.

Discussion: Overall, the limited literature on RCA effectiveness provides anecdotal evidence that RCA improves safety. At the same time, it highlights the numerous theoretical problems with the analytical framework. Formal studies at the system level and cost-benefit analysis are needed to determine the effectiveness of RCA. Structured publication of case studies will support shared knowledge and will provide benchmarks for improvement. Enrichment of the RCA literature body will enable reproducibility of improvement work, optimization of analysis, and validation of the framework itself.

Document Type: Research article

Publication date: 2008-07-01

More about this publication?

Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
Editorial Board
Information for Authors
Subscribe to this Title
Information for Advertisers
Reprints and Permissions
Index
ingentaconnect is not responsible for the content or availability of external websites

The Effectiveness of Root Cause Analysis: What Does the Literature Tell Us?

Buy & download fulltext article:

Tools

Key

Text size:

Useful pages