RCA process much like
outbreak investigation
Infection control professionals
are acutely familiar with the 12 steps listed below to conduct an outbreak investigation.
Doing a root-cause analysis (RCA) is not all that different, as shown in the
second list:1
Steps in doing an outbreak
investigation
- Confirm existence of
outbreak.
- Confirm diagnosis of
cases.
- Prepare or investigation.
- Create case definition.
- Search for additional
cases.
- Characterize epidemic
by person, place, time (line list).
- Generate tentative hypothesis.
- Test hypothesis.
- Institute additional
studies.
- Implement interventions.
- Communicate findings.
- Move to process improvement.
Steps in preparing for
an RCA
- Organize a team.
- Define the problem.
- Study the problem.
- Determine what happened.
- Identify contributing
process factors.
- Identify other contributing
factors.
- Measure � collect and
assess data on proximate and underlying causes.
- Design and implement
interim changes.
- Identify which systems
are involved � root causes.
- Prune the list of root
causes.
- Confirm root causes.
- Explore and identify
risk-reduction strategies.
- Formulate improvement
actions.
- Evaluate proposed improvement
actions.
- Design improvements.
- Ensure acceptability
of the action plan.
- Implement the improvement
plan.
- Develop measures of effectiveness
and ensure their success.
- Evaluate Implementation
of improvement efforts.
- Take additional action.
- Communicate the results.
Reference
1. Frain J, Murphy D, Dash
G, et al. Integrating Sentinel Event Analysis into Your Infection Control
Practice. Washington, DC: Association for Professionals in Infection Control
and Epidemiology; January 2004. Web: www.apic.org.
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