C489 Task 2 A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.

C489 Task 2 A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.    C489 Task 2  C489 Task 2 A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.  Step one in a RCA is to identify what happened.  The information needs to be as accurate as possible and contain as many facts as possible.  The goal is to provide full understanding of how the event occurred by reviewing all record and reports that are pertinent.  No one involved in the original error should be involved in collecting data.  Step two is determine what should have happened.  Flowcharts and graphs are helpful in this step to determine the error by comparing current policy and procedures to what occurred.    Step three is determine the cause of the error.  In this step all directly and indirectly contributing causes are reviewed.  IHI recommends asking why often in this step to narrow down the exact cause of the event.  Step four is development of a causal statement that clearly states the causative factor, the effect it had and how the main event occurred as a result.  During this step RCA team members are assigned responsibility for implementing new policy or changing existing policy to prevent future events.  IHI stresses that all policy changes need to have measurable outcomes to help refine and perfect the policy.  Step five is generate a list of recommended actions to prevent recurrence of the event.  A list usually includes refinement of policies, use of checklist to prevent error and simplification of complicated processes.  A timeline is then created