Analysis reveals the true cause of injuries

RCA questions encompass six categories

When an accident occurs, the best way to prevent a recurrence is to ask a simple question: Why did this happen? But you don't want an easy answer. Through a nonpunitive, systematic process of root-cause analysis (RCA), you will trigger many other questions.

RCA has been used in other industries, such as aviation and nuclear power, and with patient safety to find the underlying cause of errors. The Veterans Health Administration (VHA) recently adapted the process for use with employee safety — to evaluate a single lost-time injury or a pattern of similar injuries.

"It is a very nice tool that gets away from blame and finger-pointing," says Pam Hirsch, APRN, MEd, MS, clinical program manager of occupational health at the VHA. "You really look at what's happening. It makes you ask additional questions so you do get down to the real cause."

For example, when a cluster of bloodborne pathogen exposures occurred at one VHA facility, RCA helped uncover the cause. Medical residents had been trained to use a safety scalpel, but not the type at the facility. With additional training, the cluster of exposures ceased.

"As you determine that one specific issue was a root cause of the incident, you have to go back and say, 'How can I correct that?'" Hirsch says.

Removing the root cause

RCA leads to a permanent change in processes. For example, it would not be enough just to train the current medical residents to use the safety devices. A systems change would ensure that new employees, students, and residents routinely receive training in safety devices. It also would require documentation that the training took place and that the students or employees had developed a level of competency, says Hirsch.

While you obviously will need to talk to the employee about what happened after an accident, RCA casts a wider net. It often involves the supervisor and co-workers as well as employee health and safety. Interviews may be conducted one-on-one or in a focus group format. "When it comes to safety, everybody has to be involved," says Hirsch.

The Department of Veterans Affairs' National Center for Patient Safety identified six categories of questions that provide some direction for RCA:

• Human factors/communication: Questions relate to the flow of information, communication about the use of equipment and application of policies and procedures, and barriers to communication. Was communication between management and the frontline staff adequate? Was communication between front line employees adequate? Were policies and procedures communicated adequately? Did the overall culture of the facility encourage or welcome observations, suggestions, or "early warnings" from staff about risky situations and risk reduction?

• Human factors/training: Questions address both routine training and special training needs. Was there a program to identify what is actually needed for training of staff? Was training provided prior to the start of the work process? Were the results of training monitored over time? Was the training adequate? If not, consider the following factors: supervisory responsibility, procedure omission, flawed training, or flawed rules, policy, or procedure.

• Human factors/fatigue/scheduling: Questions probe the influence of stress, fatigue, work-load, and environmental distractions. Were the levels of vibration, noise, or other environmental conditions appropriate? Did personnel have adequate sleep? Did scheduling allow personnel adequate sleep? Was there sufficient staff on hand for the workload at the time?

• Environment/equipment: Questions evaluate the use, maintenance, and location of equipment and the suitability of the environment. Was the work area/environment designed to support the function it was being used for? Had there been an environmental risk assessment (i.e., safety audit) of the area? Did the work area/environment meet current codes, specifications, and regulations? Was there adequate equipment to perform the work processes? Was the equipment designed such that usage mistakes would be unlikely to happen? Were personnel trained appropriately to operate the equipment involved in the adverse event/close call?

• Rules/policies/procedures: Questions assess the usefulness of directives; the compliance with codes, standards, regulations and safety measures; and the availability of information to students, volunteers, and temporary or part-time workers. Did management have an audit or quality control system to inform them how key processes related to the adverse event are functioning? Had a previous audit been done for a similar event, were the causes identified, and were effective interventions developed and implemented on a timely basis? Would this problem have gone unidentified or uncorrected after an audit/review? Were there written, up-to-date policies and procedures that addressed the work processes related to the adverse event or close call? Were relevant policies/procedures clear, understandable, and readily available to all staff? Were the relevant policies and procedures actually used on a day-to-day basis?

• Barriers: Questions address the barriers that are in place to prevent accidents and injuries, such as safety devices. What barriers and controls were involved in this adverse event or close call? Were these barriers designed to protect patients, staff, equipment, or environment? Were these barriers and controls in place before the event happened? Would the adverse event have been prevented if the existing barriers and controls had functioned correctly?

(Editor's note: Additional tools for conducting an RCA are available from the VA's National Center for Patient Safety at