RCA:  

A root cause analysis should be performed as soon as possible after the error or variance occurs.  Otherwise, important details may be missed.  All of the personnel involved in the error must be involved in the analysis.  Without all parties present, the discussion may lead to fictionalization or speculation that will dilute the facts.  Asking for this level of involvement may cause staff to feel hostile, defensive, or apprehensive.  Managers must explain that the purpose of the root cause analysis process is to focus on the setting of the error and the systems involved.  Managers should also stress that the purpose of the analysis is not assign blame.  

• Identify Possible Factors
• Identify the Root Cause
• Identify Communication Challenges
• Prioritize Communication Challenges