Recasting the RCA: An improved model for performing root cause analyses

Julius Cuong Pham, George R. Kim, Jeffrey P. Natterman, Renee M. Cover, Christine A. Goeschel, Albert W. Wu, Peter J. Pronovost

Research output: Contribution to journalArticlepeer-review

31 Scopus citations


The root cause analysis (RCA) process is used to investigate adverse events. However, it may not reduce the risk of recurrence as effectively as intended. The authors propose adapting a risk prioritization and reduction process modeled after the Commercial Aviation Safety Team (CAST). The process involves the following: (a) increasing effectiveness of selected interventions by prioritizing each cause/contributing factor based on its role in the current sentinel event as well as in future events; interventions are then selected based on their ability to remediate the root causes/contributing factors and the likelihood of successful implementation; (b) measuring effectiveness of intervention implementation; and (c) evaluating effectiveness of the interventions by measuring the rates of event recurrence, near misses, contributing factors, mitigating factors, and staff perceptions of risk. Teams that evaluate intervention effectiveness are independent of those that implement the intervention. This framework seeks to improve the RCA process and provide further insights into advancing patient safety.

Original languageEnglish (US)
Pages (from-to)186-191
Number of pages6
JournalAmerican Journal of Medical Quality
Issue number3
StatePublished - May 2010


  • Adverse event
  • CAST
  • Medical error
  • Root cause analysis
  • Sentinel event

ASJC Scopus subject areas

  • Health Policy


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