Goals - to identify:
(1) what precisely happened
(2) why it happened
(3) what can be done to prevent it from happening again
Elements:
(1) identification of causal factors (human, device, etc)
(2) identification of related processes and systems that may have contributed
(3) analysis of underlying cause and effect systems all the way down to the "roots"
(4) identification of risk factors and how they contributed and interacted
(5) identification of specific ways to improve processes or systems
Ideally the process:
(1) should be impartial and blame-free
(2) be interdisciplinary and be supported by the leadership of the organization
(3) involve people with appropriate expertise and those most familiar with the situation
(4) should continue digging until the roots of the problem have been identified and cause-effect relationships have been defined
(5) be internally consistent
(6) be evidence-based with consideration of the relevant literature, standards of care and guidelines
Rules for causal statements:
(1) A causal statement must clearly state the "cause and effect" relationship
(2) A causal statement should not include negative descriptors.
(3) A preceding cause should be identified for each human error.
(4) A preceding cause should be identified for each procedural deviation.
(5) Identifying a failure to act as a cause requires that there be a pre-existing duty to act or perform (based on standards of care or guidelines for practice).
Limitations:
• The process can be effective if done properly. It can also degenerate into a dysfunctional ritual.
• It is unlikely to produce usable results if done incorrectly or incompletely.
• Barriers may include lack of understanding, lack of time, lack of resources, lack of cooperation, and lack of organizational support.
