Root Cause Analysis (TX)

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The root cause is “the evil at the bottom” that sets in motion the entire cause-and-effect chain causing the problem. If errors in the health care system are not researched to find what caused them, the error rate will continue to rise.

In 2008, Rick Croteau, JCAHO patient safety chief, stated, “if you do a really good root-cause analysis, the result is a perfect plaintiff’s case. The lawyers drool over that information”. Unfortunately, the statement above is a leading reason for non-reporting of medical errors. As healthcare professionals who strive to provide good care for patients, it is of utmost importance that every avenue is taken to ensure that patients receive the very best of care. Errors do and will occur, but it is the responsibility of each clinician and every organization to perform thorough studies to find out why errors/events occur, so that solutions/processes can be implemented to avoid similar errors in the future.

The history of root cause analysis (RCA) goes back to the need of the industrial industry to analyze and correct accidents and is also connected to the broader field of TQM (total quality management). The health care industry widely uses RCA as set by example of JCAHO for more than a decade. Clinical teams can look at all the acts related to a harmful incident, or near misses, identify the cause (root), and work to create solutions to prevent these incidents from recurring.

Two important and misunderstood facts concerning root cause analysis are: 1) root cause analysis is a management tool, not a patient care tool even though it is focused on patient safety; and 2) the main goal is to prevent human error, but root cause analysis is designed to examine the entire system and processes. RCA is NOT designed to blame individuals. With this information in mind, let’s look at how a clinician can utilize the root cause analysis.

Everyday, physical therapists perform simple versions of a root cause analysis. Nancy Kirsch, PT, DPT, PhD stated, “We have a systems perspective, which is what root cause analysis is. We do root cause analysis all the time in terms of patient management. We don’t just treat symptoms; we look at the sources of pain and work to eliminate the cause.” And Biagio Mazza, PT, MPT, OCS, SCS says, “Our whole work is problem solving around the patient need. We don’t just start treating patients who walk in and say “My back hurts”, instead we do a solid exam. We ask, ‘What is the underlying cause of the back pain’.”

In a root cause analysis, we work from the result to determine what actions lead to the result. For example, a patient was burned by a hot pack, in the root cause analysis, the team will work backward from this point to determine how and why the patient was burned during treatment.

The root cause analysis looks to determine the origin of a problem. Specific steps are taken so we can: 1) determine what happened; 2) determine why it happened; and 3) figure out how to reduce the chances of it happening again. There are 3 basic causes to a problem: 1) physical causes; 2) human causes, and 3) organizational causes, and the root cause analysis looks at all three. Many times the RCA will determine there are multiple causes.

The root cause analysis has 5 steps (some sources only list 4):

1) Define the problem (step that some sources do not include)

– What do you see happening?

– Are there specific symptoms – if so, what are they?

2) Data collection

– Everyone must understand the problem before it can be analyzed.

– Include everyone that can add information from front desk to clinicians to help gain

a better understanding of the problem.

3) Identify or chart causal factors

– What order of events leads to the problem?

– What conditions allow problem to occur?

To identify causal factors, it is a good idea to employ the “5 Whys”, for example:

A patient was burned by a hot pack




They did not let the therapist know they were uncomfortable




The therapist did not check the patient to make sure there was no burning and/or therapist did not let the patient know to notify the therapist if they became uncomfortable




The therapist did not know this was the protocol




The therapist did not complete orientation




The trainer did not have an up to date checklist for orientation

By the time why has been asked 5 times, you will usually be at the root of the problem.

4) Root Cause Identification – the identification of the underlying reason or reasons for each causal factor

– Why does the causal factor exist?

– What is the real reason the problem occurred?

5) Generate and Implement Solutions

Once the team has come to a conclusion on what changes are needed, the greatest hurdle may be to make the change and sustain it.

The last point a therapist should remember about root cause analysis, it that the same techniques can be applied to other areas in therapy such as, why is there a large number of no-shows (affects financials, scheduling and more).

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