Overview

Perhaps the most significant aspect of root cause analysis is the final step. Following the identification of root cause(s) for a particular causal factor, recommendations for preventing its recurrence must be generated. The identification of effective corrective actions is addressed explicitly in the definition of root causes. Root causes are defined as the most basic causes that can reasonably be identified, which management has control to fix and for which effective recommendations for preventing recurrence can be generated. The emphasis is on correcting the problem so that it will not be repeated. The following criteria for ensuring the viability of corrective actions are suggested.

• Will these corrective actions prevent recurrence of the condition or event?

• Is the corrective action within the capability of the organization to implement?

• Are the recommendations directly related to the root causes?

• Can we ensure that implementation of the recommendation will not introduce unacceptable risks?

The corrective actions developed should address not only the specific circumstances of the event that occurred, but also system improvements aimed at the incident's root causes. They should address options for reducing the frequency, minimizing the personnel exposures, and/or lessening the consequences of one or more of the root causes.

In general, three types of recommendations should be generated for each root cause:

• Correct the specific problem

• Correct similar existing problems

• Correct the system that created the problems

For example, if a procedure error is discovered, the following three recommendations may be generated:

• Correct the specific procedure that caused...