근본원인분석의 진실과 오해

Abstract

We introduced guidelines, cases, and educational materials that helped perform Root Cause Analysis (RCA), while suggesting the limitations of RCA and ways to overcome them to make it more active in the Republic of Korea. By arranging the existing major domestic and foreign literature on RCA, helpful information on RCA is provided to practitioners. RCA utilizes several tools to find an incident’s systematic cause rather than a single methodology. Depending on the institution, various guidelines for RCA are presented, and the RCA step suggested by The Joint Commission is often used. Moreover, various software that help perform RCA, and the Korean RCA software provided by the Korea Institute for Healthcare Accreditation can be used. Although many medical institutions perform RCA, dedicated patient safety personnel have experienced difficulties in almost all stages of RCA. Therefore, efforts to clarify problems with RCA by analyzing various cases are important. To successfully perform RCA, it is necessary to support the capacity building of dedicated patient safety personnel and RCA teams, share RCA cases, utilize RCA software, and establish a patient safety culture in medical institutions. For the potential effects of RCA to be properly demonstrated, its correct understanding is imperative.