What is Root Cause Analysis (RCA)?

Swiss cheese model of accident causation » What is Root Cause Analysis (RCA)?

Swiss cheese model of accident causation

It is the investigational process of determining underlying issues or root causes that contribute to incidents with a significant undesirable or adverse outcome – a way of doing a thorough study that involves:

  • Carefully detailing and analyzing the sequence of events/condition with input from all involved parties.
  • Determining deviations from standards within the processes involved.
  • Identifying contributory and potential contributory factors to the event.
  • Identifying incidental findings – elements that are discovered that need improvement but that did not contribute to the critical event under review.
  • Literature review to establish evidence based practices.
  • And a resulting report that gives the Findings and Recommendations of the RCA group in relation to the investigation undertaken.

The purpose of the RCA is to review our systems and processes in order to prevent a similar incident from re– occurring after we have determined the root cause of the incident


Pharmacist, CPHQ, CHQO, Quality Coordinator, Chemotherapy Preparation incharge. Graduated pharmacy school in 2009 I stood with my classmates as we recited the “Oath of a Pharmacist” in. There is one particular vow that stood out to me as we recited the Oath and I embrace this vow, “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.” I love being a pharmacist because it allows me to use my knowledge, abilities, and talents to improve patient outcomes in the community hospital in which I am employed as the pharmacy clinical coordinator.

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