• TS: – Responding to Sentinel Events Conducting an Effective Root Cause Analysis[®] [REF: JCCAP, JCSC, LDR, MDx, RNx, SFT] The Source, February 2013, Vol 11, #2, Pg 12

Although they have books you can buy, TJC has provided very few articles in its periodicals explaining the root cause analysis (RCA) process.  Beyond the requirements of LD.04.04.05, the RCA has a foundational role in preventing the recurrence of sentinel events and reducing serious risks.  As such, it is a critical function that every hospital should have mastery of.  Primarily for that reason (and its rarity), we have categorized what is otherwise a rather mundane article as having reference importance.  Its high points are:
• Enumeration of 12 “essential steps in conducting a root cause analysis”  taken from its book The Essential Guide for Patient Safety Officers.
• A Sample Fishbone Diagram targeting a death by suicide in a mental health unit on page 15.
• A worthwhile reminder that completion of an RCA tool (e,g,m Fishbone Diagram) is not equivalent to or suffice as a completed RCA.
Other standard recommendations include involving leadership, reviewing literature and communicating effectively with leadership (entire process) and staff (for implementation of action plans).
Tip: For more detailed information and references, see SPHCC Resources: Root Cause Analysis (RCA)