VA National Center for Patient Safety - Cuture Change: "The goal of a Root Cause Analysis is to find out
* What happened
* Why did it happen
* What to do to prevent it from happening again.
Root Cause Analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.
In Root Cause Analysis, basic and contributing causes are discovered in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence."