---
title: Root Cause Analysis and Process Improvement for Patient Safety
description: Root Cause Analysis and Process Improvement for Patient Safety
image: https://blog.minitab.com/hubfs/B2BML%20-%20NEW%20FILE%20MANAGER%20STRUCTURE/Blog%20Images/Imported_Blog_Media/doctor_button-3.jpg
---
English
- [English](https://blog.minitab.com/en/?hsLang=en)
- [Français](https://blog.minitab.com/fr/?hsLang=en)
- [Deutsch](https://blog.minitab.com/de/?hsLang=en)
- [Português](https://blog.minitab.com/pt/?hsLang=en)
- [Español](https://blog.minitab.com/es/?hsLang=en)
- [日本語](https://blog.minitab.com/ja/?hsLang=en)
- [한국어](https://blog.minitab.com/ko/?hsLang=en)
- [中文（简体）](https://blog.minitab.com/zh/?hsLang=en)
- [ Partners](https://www.minitab.com/en-us/company/partners/)
- [ Contact](https://www.minitab.com/en-us/company/contact-us/)
- [ Talk to Minitab](https://www.minitab.com/en-us/talk-to-minitab/)
- [ My Account](https://licensing.minitab.com/account/manage)
[](https://www.minitab.com/en-us/)
- Products
Back
[Products](https://www.minitab.com/en-us/products/)
[All Products](https://www.minitab.com/en-us/products/)
- [Minitab Solution Center](https://www.minitab.com/en-us/products/minitab-solution-center/)
- [Minitab Statistical Software](https://www.minitab.com/en-us/products/minitab/)
- [Minitab Connect](https://www.minitab.com/en-us/products/connect/)
- [Minitab Model Ops](https://www.minitab.com/en-us/products/model-ops/)
- [Minitab Education Hub](https://www.minitab.com/en-us/products/education-hub/)
- [Minitab Engage](https://www.minitab.com/en-us/products/engage/)
- [Minitab Workspace](https://www.minitab.com/en-us/products/workspace/)
- [Real-Time SPC](https://www.minitab.com/en-us/products/real-time-spc/)
- [Prolink Data Collection & SPC](https://www.minitab.com/en-us/products/prolink)
- [Simul8 Discrete Event Simulation](https://info.minitab.com/en/new-to-simul8?hsLang=en)
- [SPM](https://www.minitab.com/en-us/products/spm/)
- Solutions
Back
[Solutions](https://www.minitab.com/en-us/solutions/)
[All Solutions](https://www.minitab.com/en-us/solutions/)
- [Analytics](https://www.minitab.com/en-us/solutions/analytics/)
- [Statistics & Predictive Analytics](https://www.minitab.com/en-us/solutions/analytics/statistical-analysis-predictive-analytics/)
- [Data Science & Machine Learning](https://www.minitab.com/en-us/solutions/analytics/data-science-machine-learning/)
- [Business Analytics & Intelligence](https://www.minitab.com/en-us/solutions/analytics/business-analytics-intelligence/)
- [Statistical Process Control](https://www.minitab.com/en-us/solutions/analytics/statistical-process-control/)
- [Quality Analytics](https://www.minitab.com/en-us/solutions/analytics/quality-analytics/)
- [Live Analytics](https://www.minitab.com/en-us/solutions/analytics/live-analytics/)
- [Reliability & Life Data Analysis](https://www.minitab.com/en-us/solutions/analytics/reliability/)
- [Discrete Event Simulation](https://info.minitab.com/en/new-to-simul8?hsLang=en)
- [Process Mining](https://info.minitab.com/en/new-to-simul8?hsLang=en)
- [Key Capabilities](https://www.minitab.com/en-us/solutions/key-capabilities/)
- [Continuous Improvement](https://www.minitab.com/en-us/solutions/key-capabilities/continuous-improvement/)
- [Data Integration & Data Prep](https://www.minitab.com/en-us/solutions/key-capabilities/data-integration-data-prep/)
- [Diagramming & Mind Mapping](https://www.minitab.com/en-us/solutions/key-capabilities/diagramming-mind-mapping/)
- [Digital Twins](https://info.minitab.com/en/new-to-simul8?hsLang=en)
- [Model Deployment & ML Ops](https://www.minitab.com/en-us/solutions/key-capabilities/model-deployment-ml-ops/)
- [Innovation & Project Management](https://www.minitab.com/en-us/solutions/key-capabilities/innovation-project-management/)
- [Process Excellence: Detect, Correct & Prevent](https://www.minitab.com/en-us/solutions/key-capabilities/process-excellence/)
- [Featured Industries](https://www.minitab.com/en-us/solutions/industry/)
- [Academic](https://www.minitab.com/en-us/solutions/industry/academic/)
- [Energy & Natural Resources](https://www.minitab.com/en-us/solutions/industry/energy-resources/)
- [Government & Public Sector](https://www.minitab.com/en-us/solutions/industry/government/)
- [Healthcare](https://www.minitab.com/en-us/solutions/industry/healthcare/)
- [Insurance](https://www.minitab.com/en-us/solutions/industry/insurance/)
- [Manufacturing & Industrial](https://www.minitab.com/en-us/solutions/industry/manufacturing-industrial/)
- [Services](https://www.minitab.com/en-us/solutions/industry/service-industries/)
- [Software & Technology](https://www.minitab.com/en-us/solutions/industry/software-technology/)
- [Construction](https://www.minitab.com/en-us/solutions/industry/construction/)
- [Featured Roles](https://www.minitab.com/en-us/solutions/role/)
- [Engineering](https://www.minitab.com/en-us/solutions/role/engineering/)
- [Business Analysis](https://www.minitab.com/en-us/solutions/role/business-analysts/)
- [Information Technology](https://www.minitab.com/en-us/solutions/role/information-technology/)
- [Supply Chain](https://www.minitab.com/en-us/solutions/role/supply-chain/)
- [Customer Service & Contact Center](https://www.minitab.com/en-us/solutions/role/customer-service-contact-center/)
- [Human Resources](https://www.minitab.com/en-us/solutions/role/human-resources/)
- [Marketing](https://www.minitab.com/en-us/solutions/role/marketing/)
- [Research and Development](https://www.minitab.com/en-us/solutions/role/research-and-development/)
- Resources & Services
Back
[Resources & Services](https://www.minitab.com/en-us/resources-services/)
[All Resources & Services](https://www.minitab.com/en-us/resources-services/)
- [Resources](https://www.minitab.com/en-us/resources-services/resources/)
- [Case Studies](https://www.minitab.com/en-us/resources-services/resources/case-studies/)
- [eBooks & White Papers](https://www.minitab.com/en-us/resources-services/resources/ebooks-and-white-papers/)
- [Blog](https://blog.minitab.com/blog/?hsLang=en)
- [Data Sets](https://www.minitab.com/en-us/resources-services/resources/data-set/)
- [Webinars & Events](https://www.minitab.com/en-us/resources-services/resources/events/)
- [Education Hub](https://www.minitab.com/en-us/resources-services/resources/education-hub/)
- [Services](https://www.minitab.com/en-us/resources-services/services/)
- [Training](https://www.minitab.com/en-us/resources-services/services/training/)
- [Deployment](https://www.minitab.com/en-us/resources-services/services/deployment/)
- [Consulting](https://www.minitab.com/en-us/resources-services/services/statistical-consulting/)
- [Self-Paced Learning](https://www.minitab.com/en-us/resources-services/services/self-paced-learning/)
- [Continuing Education](https://www.minitab.com/en-us/resources-services/services/continuing-education/)
- Support
Back
[Support](https://www.minitab.com/en-us/support/)
[Technical Support](https://www.minitab.com/en-us/support/)
- [Subscriptions & Activation](https://www.minitab.com/en-us/support/subscriptions-and-activation/)
- [Minitab Quick Start](https://www.minitab.com/en-us/support/quick-start/)
- [Training](https://www.minitab.com/en-us/resources-services/services/training/)
- [Installation Support](https://www.minitab.com/en-us/support/installation/)
- [Support Videos](https://www.minitab.com/en-us/support/videos/)
- [Support Documentation](https://www.minitab.com/en-us/support/documents/)
- [Software Updates](https://www.minitab.com/en-us/support/software-updates/)
- [Product Downloads](https://www.minitab.com/en-us/support/downloads/)
- [Support Policy](https://www.minitab.com/en-us/support/policy/)
- Company
Back
[Company](https://www.minitab.com/en-us/company/)
[Company](https://www.minitab.com/en-us/company/)
- [About Us](https://www.minitab.com/en-us/company/our-company/)
- [Leadership Team](https://www.minitab.com/en-us/company/leadership-team/)
- [Partners](https://www.minitab.com/en-us/company/partners/)
- [Careers](https://www.minitab.com/en-us/company/careers/)
- [Contact](https://www.minitab.com/en-us/company/contact-us/)
- [News](https://www.minitab.com/en-us/company/press-releases/)
[Try/Buy](https://www.minitab.com/en-us/try-buy/)
- [Statistics](https://blog.minitab.com/en/blog/tag/statistics)
- [Data Analysis](https://blog.minitab.com/en/blog/tag/data-analysis)
-
- [Quality Improvement](https://blog.minitab.com/en/blog/tag/quality-improvement)
- [Subscribe](https://info.minitab.com/blog/subscribe?hsLang=en)
## Notice
You are now leaving minitab.com.
Click Continue to proceed to:
Continue
Go Back
# Root Cause Analysis and Process Improvement for Patient Safety
Minitab Blog Editor | 6/22/2012
Topics: [Healthcare](https://blog.minitab.com/en/blog/tag/healthcare), [FMEA](https://blog.minitab.com/en/blog/tag/fmea), [Quality Improvement](https://blog.minitab.com/en/blog/tag/quality-improvement), [Six Sigma](https://blog.minitab.com/en/blog/tag/six-sigma), [Lean Six Sigma](https://blog.minitab.com/en/blog/tag/lean-six-sigma)
- [Share](https://www.linkedin.com/shareArticle?mini=true&url=https://blog.minitab.com/en/blog/understanding-statistics/root-cause-analysis-and-process-improvement-for-patient-safety)
- [Share](https://www.facebook.com/sharer.php?u=https://blog.minitab.com/en/blog/understanding-statistics/root-cause-analysis-and-process-improvement-for-patient-safety)
Every so often I get to interview someone who applies quality methodology in ways I wouldn't have imagined before I began working at Minitab. For instance, I spoke with the quality manager for a world-renowned medical center not long ago. This facility is consistently included in *U.S. News and World Report*'s list of America’s Best Hospitals, but even the best hospitals occasionally have “sentinel events,” incidents that result in death or serious injury unrelated to the natural course of a patient’s illness.
Healthcare providers are required to determine what went wrong in a sentinel event and develop a plan to keep it from happening again.
This investigation, called a Root Cause Analysis (RCA), can be extremely complicated. The RCA is conducted by a multidisciplinary team comprising members of the affected departments. The team explores and analyzes all potential causes of the event, identifies risk reduction strategies, then implements a correction plan. “The RCA helps us carefully analyze and understand precisely what happened, and learn how how to avoid similar events in the future,” the hospital's quality manager told me. “Doing it right is critical to helping us ensure patient safety.”
The RCA team and staff involved in the event review what happened in great detail. Participants may even need to reenact the event. Meanwhile, the RCA team observes and asks questions. Were any policies or procedures breached? What role did staffing, equipment, supplies, or communication play? To find the root of the problem, it is important to keep asking “Why?” The knowledge gained from the RCA is used to develop and implement practices to reduce the risk of a similar event in the future. The plan should include a method for monitoring the effectiveness of new systems or procedures.
The RCA process can be daunting and costly. “It’s very labor-intensive, and that makes it expensive,” the quality manager explained. “We may need six to eight people on a team, and we create an enormous amount of information along the way. We want to do every RCA right, but we also want it to be as efficient and consistent as possible.”
But when the hospital began doing RCAs, existing tools made a difficult task even more challenging. “The analysis includes a host of complicated steps, and the tools we were using couldn’t handle all the things we needed to do,” the quality manager said.
That brought us to the reason for our interview: I wanted to find out how this hospital was using Minitab Engage, our [process improvement software](http://www.minitab.com/products/companion/). They didn't get Minitab Engage specifically to perform Root Cause Analyses, but it turns out the software was well suited to the task.
When an RCA begins, the team uses Engage’s built-in Roadmap™ to organize the project into phases and create a launch pad for the tools used in every task. The Roadmap outlines projects and keeps them on track. As with all of Engage’s tools, the hospital was able to easily customize the Roadmap to their needs.
To develop a clear understanding of the sequence of events, the RCA team uses process maps, flowcharts, Cause-and-Effect (C&E) diagrams, and other quality forms, all of which are included in Engage’s powerful but easy-to-use built-in soft tools. And data entered into one Engage tool is available to the software’s other tools, eliminating the need to re-enter the same information. For example, information the team puts into a process map is automatically available in the C&E Matrix tool, too.
Other Engage tools that have proven useful in the RCA process include Failure Modes and Effect Analysis (FMEA), which helps identify causes for a process failure, anticipate effects, and prioritize actions to mitigate them, and the 5S audit tool, which helps determine best practices and track the implementation of improvements.
The quality manager told me it’s hard to imagine doing an RCA without Engage now. “It's just an extremely practical solution for the challenges involved,” he said. “It’s great to have all the necessary tools right at hand. We’ve also begun using Engage to map patient flow through the facility, and we anticipate we’ll be able to apply it in many other areas, too. It’s a very powerful tool for quality improvement.”
You can see more in our short video tour, which explains how Minitab Engage software can [manage quality projects](http://www.minitab.com/products/companion).
I've talked to many people about their continuous improvement initiatives, but this was certainly one of the most eye-opening interviews I've had. Regardless of the fact they use Engage, their approach to handling sentinel events vividly illustrates just how many types of issues quality improvement methods can be applied to.
What's the most unusual or unexpected application of quality improvement you've seen?
## You Might Also Like
[Do You Really Need That New Machine? How Minitab Can Help You Find Out](https://blog.minitab.com/en/blog/do-you-really-need-that-new-machine-how-minitab-can-help-you-find-out?hsLang=en)
[Quality Improvement](https://blog.minitab.com/en/blog/tag/quality-improvement) | 4 Minute Read
[Inside the 2025 IHI Forum: What Healthcare Leaders Are Saying About AI](https://blog.minitab.com/en/blog/ihi-forum-healthcare-and-ai?hsLang=en)
[Minitab Ai](https://blog.minitab.com/en/blog/tag/minitab-ai) | 5 Minute Read
[VDA, AIAG, MSA Oh My! Can Someone Please Explain the Different Measurement System Analysis Methodologies to Me?](https://blog.minitab.com/en/blog/vda-aiag-msa-oh-my?hsLang=en)
[Minitab Solution Center](https://blog.minitab.com/en/blog/tag/minitab-solution-center) | 4 Minute Read
---
- [Careers](https://www.minitab.com/en-us/company/careers/)
- [Trust Center](https://www.minitab.com/en-us/trust-center/)
- [Suppliers](https://www.minitab.com/en-us/suppliers/)
- [Site Map](https://www.minitab.com/en-us/site-map/)
- [](https://www.linkedin.com/company/minitab/)
- [](https://www.facebook.com/Minitab/)
- [](https://www.youtube.com/user/MinitabInc)
- [](https://www.instagram.com/minitab/)
---
© 2025 Minitab, LLC. All Rights Reserved.
- [Terms of Use](https://www.minitab.com/en-us/legal/terms-of-use/)
- [Privacy Policy](https://www.minitab.com/en-us/legal/privacy-policy/)
- [Legal](https://www.minitab.com/en-us/legal/)
- Cookies Settings