Document Type : Review Article


Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (causes) in causal factors that its revision or removing caused to prevent the recursion of a situation such as an error when is occurring in a process.The process of root cause analysis is consist of six steps: the beginning of the process, Data collection and mapping information, Identifying the problems, Analyzing Information, Solution Providing, Implementing the solutions (action plans),Writing the report.


Kaushal RK, Nema AK. Multi-stakeholder decision analysis and comparative risk assessment for reuse- recycle oriented e-waste management strategies: a game theoretic approach. Waste Manag Res 2013 Jul 15.

Simon RW, Canacari EG. A practical guide to applying lean tools and management principles to health care improvement projects. AORN J 2012; 95(1):85-100.

Graves K, Simmons D, Galley MD. Cause-and-effect mapping of critical events. Crit Care Nurs Clin North Am 2010;22(2):243-51.

Clancy TR, Effken JA, Pesut D. Applications of complex systems theory in nursing education, research, and practice. Nurs Outlook 2008; 56(5):248-256.e3.

Rovira E, McGarry K, Parasuraman R. Effects of imperfect automation on decision making in a simulated command and control task. Hum Factors. 2007 Feb; 49(1):76-87.

Benedetto AR. Six Sigma: not for the faint of heart. Radiol Manage 2003; 25(2):40-53.

Breen AM, Burton-Houle T, Aron DC. Applying the theory of constraints in health care: Part 1--The philosophy. Qual Manag Health Care 2002;10(3):40-6.

Alemi F, Neuhauser D, Ardito S, Headrick L, Moore S, Hekelman F, Norman L. Continuous self-improvement: systems thinking in a personal context. Jt Comm J Qual Improv 2000;26(2):74-86.

Kogi K. Collaborative field research and training in occupational health and ergonomics. Int J Occup Environ Health 1998;4(3):189-95.

Benson R, Harp N. Using systems thinking to extend continuous quality improvement. Qual Lett Healthc Lead 1994;6(6):17-24.

Schwarz D, Stourač P, Komenda M, Harazim H, Kosinová M, Gregor J,et al. Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET. J Med Internet Res. 2013;15(7):e135.

Braun R, Catalani C, Wimbush J, Israelski D. Community health workers and mobile technology: a systematic review of the literature. PLoS One 2013; 8(6):e65772.

Farias M, Jenkins K, Lock J, Rathod R, Newburger J, Bates DW,et al. Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines. Health Aff (Millwood) 2013;32(5):911-20.

Weber C, Jakola AS, Gulati S, Nygaard OP, Solheim O. Evidence-based clinical management and utilization of new technology in European neurosurgery. Acta Neurochir (Wien) 2013;155(4):747-54.

Siekmeier R, Halbauer J, Mientus W, Wetzel D. Safety of laboratory analyzers for infection testing - results of the market surveillance by the BfArM until End 2007. J Physiol Pharmacol 2008;Suppl 6:629-43.

Varkey P, Karlapudi SP, Bennet KE. Teaching quality improvement: a collaboration project between medicine and engineering. Am J Med Qual 2008; 23(4):296-301.

Day S, Dalto J, Fox J, Turpin M. Failure mode and effects analysis as a performance improvement tool in trauma. J Trauma Nurs 2006;13(3):111-7.

Amo MF. Root cause analysis. A tool for understanding why accidents occur. Balance 1998; 2(5):12-5.

Khorsandi M, Skouras C, Beatson K, Alijani A. Quality review of an adverse incident reporting system and root cause analysis of serious adverse surgical incidents in a teaching hospital of Scotland. Patient Saf Surg 2012; 6(1):21.

Seidl KL, Newhouse RP. The intersection of evidence-based practice with 5 quality improvement methodologies. J Nurs Adm 2012;42(6):299-304.

Silich SJ, Wetz RV, Riebling N, Coleman C, Khoueiry G, Abi Rafeh N,et al. Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds. J Healthc Qual 2012; 34(1):44-54.

Siekmeier R, Halbauer J, Mientus W, Wetzel D. Safety of laboratory analyzers for infection testing - results of the market surveillance by the BfArM until End 2007. Eur J Med Res 2009;14 Suppl 4:216-26.

Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process. Qual Saf Health Care 2010; 19(6):e64.

Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med 2010; 85(9):1425-39.

Pham JC, Kim GR, Natterman JP, Cover RM, Goeschel CA, Wu AW, et al. ReCASTing the RCA: an improved model for performing root cause analyses. Am J Med Qual 2010;25(3):186-91.

Cohen SP, Hayek SM, Datta S, Bajwa ZH, Larkin TM, Griffith S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology 2010; 112(3):711-8.

Cahill K, Cruz E, Guilbert MB, Oser MO. Root cause analysis following nephrectomy after extracorporeal shockwave lithotripsy (ESWL). Urol Nurs 2008;28(6):445-53.

Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008; 299(6):685-7.

Iedema R, Jorm C, Braithwaite J. Managing the scope and impact of root cause analysis recommendations. J Health Organ Manag 2008;22(6):569-85.

Lundy D, Laspina S, Kaplan H, Rabin Fastman B, Lawlor E. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. Vox Sang 2007; 92(3):233-41.

Collins SA, Bavuso K, Zuccotti G, Rocha RA. Lessons learned for collaborative clinical content development. Appl Clin Inform 2013 Jun 26; 4(2):304-16.

Black K, Revere L. Six Sigma arises from the ashes of TQM with a twist. Int J Health Care Qual Assur Inc Leadersh Health Serv 2006; 19(2-3):259-66.

Yates GR, Hochman RF, Sayles SM, Stockmeier CA. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Jt Comm J Qual Saf 2004;30(10):534-42.

Hellwig SD, Piper L, Naylor E. Forty hours under pressure: a rapid-response improvement team achieves synergy. J Healthc Qual 2002;24(3):21-3,

Revere L, Black K. Integrating Six Sigma with total quality management: a case example for measuring medication errors. J Healthc Manag 2003; 48(6):377-91.

Snow RJ, Engler D, Krella JM. The GDAHA hospital performance reports project: a successful community-based quality improvement initiative. Qual Manag Health Care 2003; 12(3):151-8.

Carroll JS, Rudolph JW, Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care 2002; 11(3):266-9.

Mawji Z, Stillman P, Laskowski R, Lawrence S, Karoly E, Capuano TA, et al. First do no harm: integrating patient safety and quality improvement. Jt Comm J Qual Improv 2002; 28(7):373-86.

Weinberg N. Using performance measures to identify plans of action to improve care. Jt Comm J Qual Improv 2001; 27(12):683-8.

Handley CC. Quality improvement through root cause analysis. Hosp Mater Manage Q 2000; 21(4):74-8.

Croteau R. Sentinel events, root cause analysis, and proactive risk reduction. Ambul Outreach 1999 Fall: 19-22.

Hirsch KA, Wallace DT. Conduct a cost-effective RCA (root-cause analysis) by brainstorming. Hosp Peer Rev 1999; 24(7):105-6, 111-2.

Graber ML. Physician participation in quality management. Expanding the goals of peer review to detect both practitioner and system error. Jt Comm J Qual Improv 1999; 25(8):396-407.

Lepley CJ. Affinity maps and relationship diagrams: two tools to enhance performance improvement. J Nurs Care Qual 1999; 13(3):75-83.

Weinberg NS, Stason WB. Managing quality in hospital practice. Int J Qual Health    Care 1998; 10(4):295-302.

Schommer JC, Worley MM, Kjos AL. Decision-making during initiation of medication therapy. Res Social Adm Pharm 2013 Jul 16. doi: pii: S1551-7411(13)00103-4. 10.1016/j. sapharm.2013.06.003.

Cross LA. Value-based leadership. A prescription for reforming the American health care system. Med Group Manage J 1997; 44(3):14-8, 20.

Mak DB, Plant AJ, Toussaint S. "I have learnt ... a different way of looking at people's health": an evaluation of a prevocational medical training program in public health medicine and primary health care in remote Australia. Med Teach 2006;28(6):e149-55.

Harolds J. Planning and conducting meetings effectively, part I: planning a meeting. Clin Nucl Med 2011; 36(12):1106-8.

Okamoto R. [Development of practical care management guidelines for community health care]. Nihon Koshu Eisei Zasshi 2001;48(9):773-84.

Handfield-Jones R, Nasmith L, Steinert Y, Lawn N. Creativity in medical education: the use of innovative techniques in clinical teaching. Med Teach 1993;15(1):3-10.

Rossi-Mori A, Pisanelli DM, Ricci FL. Evaluation stages and design steps for knowledge-based systems in medicine. Med Inform (Lond) 1990;15(3):191-204.

Poza EJ. A do-it-yourself guide to group problem solving. Personnel 1983;60(2):69-77.

Simard L, Branchaud S. [Brain storming. Interview by Charles Meunier]. Perspect Infirm 2008;5(5):15-6.

Castelan DS. Sympathetic storming in acute conditions. Crit Care Nurse 2007;27(3):19-20.

Piran N. Teachers: on "being" (rather than "doing") prevention. Eat Disord 2004;12(1):1-9

Dolansky MA, Druschel K, Helba M, Courtney K. Nursing student medication errors: a case study using root cause analysis. J Prof Nurs 2013; 29(2):102-8.

Pucher PH, Aggarwal R, Twaij A, Batrick N, Jenkins M, Darzi A. Identifying and addressing preventable process errors in trauma care. World J Surg 2013;37(4):752-8.

Agrawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf 2012;38(12):566-74.

Quraishi SA, Kimatian SJ, Murray WB, Sinz EH. High-fidelity simulation as an experiential model for teaching root cause analysis. J Grad Med Educ 2011;3(4):529-34.

Siemieniuk RA, Fonseca K, Gill MJ. Using root cause analysis and form redesign to reduce incorrect ordering of HIV tests. Jt Comm J Qual Patient Saf 2012; 38(11):506-12.

Adibi H, Khalesi N, Ravaghi H, Jafari M, Jeddian AR. Root-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety. Acta Med Iran 2012;50(9):624-31.

Tanaka M, Tanaka K, Takano T, Kato N, Watanabe M, Miyaoka H. Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study. BMJ Qual Saf 2012;21(9):784-90.

Schafer JJ. A root cause analysis project in a medication safety course. Am J Pharm Educ 2012;76(6):116.

Pinto A, Caranci F, Romano L, Carrafiello G, Fonio P, Brunese L. Learning from errors in radiology: a comprehensive review. Semin Ultrasound CT MR 2012; 33(4):379-82.

Muething SE, Goudie A, Schoettker PJ, Donnelly LF, Goodfriend MA, Bracke TM,et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics 2012;130(2):e423-31.

Tanaka K. [Medical safety and staff mental health. Seishin Shinkeigaku Zasshi 2012; 114(4):376-83.

Anderson CI, Nelson CS, Graham CF, Mosher BD, Gohil KN, Morrison CA, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res 2012;177(1):43-8.

Ison MG, Holl JL, Ladner D. Preventable errors in organ transplantation: an emerging patient safety issue? Am J Transplant 2012; 12(9):2307-12.

Maeda S, Kamishiraki E, Starkey J. Patient safety education at Japanese medical schools: results of a nationwide survey. BMC Res Notes 2012 ;5:226.

Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012; 21(5):369-80.

Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am 2012;92(1):89-100.

Sams SB, Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis. Performance, error root cause analysis, and quality improvement. Am J Clin Pathol 2012;137(2):248-54.

Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf 2012;21(4):267-70.

Huff C. Commanding safety: how the VA drives systemwide error prevention. Trustee 2011; 64(9):8-12, 1.

Duthie EA. Application of human error theory in case analysis of wrong procedures. J Patient Saf 2010;6(2):108-14.