Table 3 Root Cause Analysis steps and example

1. Define the story arc by summarizing the context and pivotal nodes (events, decisions, time points) when events could have unfolded differently and could have led to a substantially different outcome.

2. Identify the public health system’s major organizational goals or objectives in responding to the incident, including which PHEP Capabilities and IHR (2005) core capacities that were stressed.

3. Identify the major response challenges that had a qualitative impact on permitting achievement of the public health system’s goals or at least had the potential to do so.

4. Define the immediate causes of the challenges and the factors that contributed to the challenges, whether modifiable (within the jurisdiction’s influence) or not modifiable (not within the jurisdiction’s influence); note pre-event decisions and factors beyond the system’s control.

5. Identify factors that, if not addressed, are likely to limit the public health system in future incidents. With these steps in mind, RCA can help those conducting the AAR to include the deepest level of analysis within their review.