An Overview of Root Cause Analysis for Nurses

In the fast-paced and high-stakes environments of healthcare, even small mistakes can lead to serious consequences. Nurses help ensure patient safety, making it necessary to understand and use tools that promote continuous improvement and error prevention.  

One such tool is root cause analysis (RCA), a structured method for identifying underlying causes of adverse events and near misses. This article explores root cause analysis, how it can be applied in nursing, how the 5 Whys technique is used, and what templates and examples look like in practice. 

What is root cause analysis? 

The Patient Safety Network defines RCA as a “structured method used to analyze adverse events.” This tool identifies what went wrong and determines why it happened. Rather than focusing solely on individual errors, RCA seeks to uncover systemic issues that contributed to the incident, such as workflow breakdowns, communication lapses, or inadequate training. 

RCA is also used to identify latent errors and detect safety hazards. The latent errors are critical because they use RCA analysis from an adverse event, where the goal is to prevent a future adverse event. The National Patient Safety Foundation, now merged with the Institute of Healthcare Improvement (IHI), created RCA2 (Root Cause Analysis “squared”) as a tool for latent error analysis.  

With these instances, the goal isn’t to assign blame but to create solutions that prevent future occurrences. 

RCA is often used after: 

• Medication errors 
• Patient falls 
• Healthcare-associated infections (HAIs) 
• Delayed or missed diagnoses 
• Equipment failures 

Healthcare organizations typically conduct an RCA after a sentinel event, as required by accrediting bodies like The Joint Commission. 

5 Whys of root cause analysis 

While there are many tools for RCA, including the fault-tree analysis and the fishbone analysis, one of the simplest yet most effective tools is the 5 Whys technique. This method involves asking, “why?” repeatedly — usually five times — until the true root cause of an active or latent error is identified. 

Example: Medication error 

Problem: A patient received the wrong dose of insulin. 

1. Why did the patient receive the wrong dose? 
     → The nurse misread the insulin order. 
2. Why did the nurse misread the order? 
     → The handwriting on the paper chart was illegible. 
3. Why was the handwriting illegible? 
     → The order was written in a hurry during a shift change. 
4. Why was the order written during a hectic shift change? 
     → There is no standardized process for order hand-offs. 
5. Why is there no standardized hand-off process? 
     → The facility lacks a formal protocol for safe transitions. 

Root cause: Absence of a standardized hand-off protocol. 

Example: Wound care delay 

Problem: A patient’s pressure injury worsened from Stage 2 to Stage 3 due to delayed wound care. 

1. Why did the pressure ulcer worsen? 
    → The wound care was delayed for over 48 hours. 
2. Why was the wound care delayed? 
    → The wound care consult order was not seen by the wound care nurse. 
3. Why was the consult order not seen? 
    → It was entered into the electronic health record (EHR) under the wrong patient category. 
4. Why was it entered under the wrong category? 
    → The EHR system has a confusing interface with multiple, similarly labeled consult options. 
5. Why does the EHR have confusing consult options? 
    → The EHR was implemented without clinical staff input or proper user-interface testing. 

Root cause: Poor EHR design and implementation without clinical end-user input, resulting in misfiled orders and delayed wound care. 

By drilling down, the team moves from a surface-level error to a process improvement opportunity. 

Root cause analysis template for nurses 

Using a template helps guide the RCA process in a structured and consistent way. While formats may vary, a typical root cause analysis template includes the following components: 

1. Event description 

• Date, time, and location of the incident 
• Individuals involved 
• Summary of what happened 

2. Chronology (Timeline of events) 

• Step-by-step breakdown of actions leading up to the event 

3. Contributing factors 

• Environmental, human, equipment, and communication issues 

4. Root cause identification 

• Use of tools like the 5 Whys, fishbone diagrams, or flowcharts 

5. Action plan 

• Specific steps to address root causes 
• Responsible parties 
• Target dates for implementation 

6. Follow-up evaluation 

• How success will be measured 
• Date of reassessment 

Nurses involved in quality improvement or risk management teams often participate in completing or reviewing these templates. 

Examples of root cause analysis in nursing 

Example one: Patient fall 

Incident: A patient fell while attempting to go to the bathroom unassisted. 

Root cause: The call bell was out of reach, and staff were unaware of the patient's high fall risk. 

Action plan: Re-educate staff on fall risk protocols, ensure call lights are accessible, and implement hourly rounding. 

Example two: Hospital-acquired pressure injury (HAPI) 

Incident: A stage 3 pressure injury developed on a patient’s coccyx during their ICU stay. 

Root cause: Inconsistent turning schedule and lack of a pressure redistribution mattress. 

Action plan: Establish a skin care champion on each shift, revise turning protocols, and ensure high-risk patients are prioritized for specialty beds. 

Example three: Delayed antibiotic administration 

Incident: A septic patient experienced a delay in receiving antibiotics. 

Root cause: Lab results were not communicated promptly, and the nurse was covering multiple units. 

Action plan: Implement a sepsis alert protocol and reevaluate staffing assignments during peak hours. 

Why root cause analysis matters in nursing 

RCA empowers nurses to become agents of change within their organizations. By identifying patterns, challenging assumptions, and asking more profound questions, they can uncover hidden system flaws and help design safer, more effective care processes. 

Whether you’re a bedside nurse involved in a sentinel event review or a nurse leader overseeing quality initiatives, understanding RCA equips you with the skills to make meaningful, lasting improvements to promote the best possible patient outcomes.