I came across this healthcare research paper touting the value of using Root Cause Analysis (RCA) to improve patient safety, with an emphasis on LATENT ORGANIZATIONAL factors that play a role in accidents. There were so many incredible tidbits in the paper that I have summarized them below. Many of you reading this are NOT in healthcare, but this paper explains the benefits of using an RCA in any environment. Just switch the word “patient” with “employee,” and we have a perfect fit for our workplaces.
Note: the emphasis is by me; you will notice a lot of language from James Reason’s work
Root Cause Analysis (RCA) is a structured method to analyze serious adverse events. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both ACTIVE errors (errors occurring at the point of interface between humans and a complex system) and LATENT ORGANIZATIONAL errors (the hidden problems within systems that contribute to adverse events). It is one of the most widely used retrospective methods for detecting safety hazards.
RCAs should generally follow a pre-specified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of ACTIVE errors) and why the event occurred (through systematic identification and analysis of LATENT ORGANIZATIONAL).
The ultimate goal of RCA is to prevent future harm by eliminating the LATENT ORGANIZATIONAL errors that so often underlie incidents.
