How does Root Cause Analysis (RCA) differ from a blame-focused investigation, and what steps are typically included in an RCA workflow?

• A. RCA focuses on system factors to prevent recurrence; steps: define event, collect data, map timeline, identify contributing factors, develop root causes, propose fixes, implement, monitor.
• B. RCA assigns blame to individuals; steps to identify culprit.
• C. RCA is only used for equipment failure; steps include ordering replacement parts.
• D. RCA is a financial audit.

Answer: (A)

Root Cause Analysis focuses on uncovering the underlying system factors and process weaknesses that allow an incident to occur, so changes can prevent recurrence rather than assigning blame. It emphasizes learning and improvement across the organization, not punishing individuals.

In an RCA workflow, you begin by defining the event and assembling the team, then collect data to understand what happened and when. You map the timeline to see the sequence of events and identify contributing factors. Next you probe to determine root causes—often using structured approaches like the 5 Whys or fishbone diagrams—centered on systemic issues rather than personal fault. After pinpointing root causes, you propose fixes that address the underlying processes or systems, not just the symptoms. Finally, you implement the changes and establish monitoring to verify effectiveness and sustain the improvements, with follow-up to ensure the fixes reduce risk over time.

The other approaches don’t fit because blaming individuals is the opposite of RCA’s intent, which is to improve systems. Limiting RCA to equipment failures or treating it as a financial audit misses the broad focus on processes, systems, and patient safety.