Root Cause Analysis Guidelines

Root Cause Analysis (RCA) is a tool used to determine the cause of deviations from procedure, practice and/or expected results. The goal of carrying out an RCA is to learn what happened, to identify the contributing factors that lead to the issue and to identify ways in which the system may be improved upon to prevent recurrence. RCA utilizes the experience and expertise of those performing the analysis, and uses common sense techniques which produce a documented, quantified and systematic approach to identifying, understanding and resolving underlying causes.

Read the Office of Chief Medical Examiner Root Cause Analysis Guidelines