Root cause analysis with 5 Whys and fishbone: causal statements and stronger actions

Skills you'll practise

• Write a problem statement that describes a pattern with data, not a single event or a person
• Build a fishbone diagram using the five classic categories and drill each cause down until it can be tested
• Run a 5 Whys analysis that follows more than one branch and backs each answer with evidence
• Write causal statements that meet the Five Rules of Causation
• Choose at least one stronger or intermediate action for each cause, with an owner, a due date and a measure

Course outline

1. 1.Writing the problem as a pattern with dataLesson · 12 min
2. 2.Building a fishbone diagram with causes you can testLesson · 14 min
3. 3.Running a 5 Whys analysis that follows more than one branchLesson · 14 min
4. 4.Writing causal statements that meet the Five Rules of CausationLesson · 12 min
5. 5.Choosing stronger actions with an owner, a date and a measureLesson · 10 min
6. 6.Root cause analysis with 5 Whys and fishbone: causal statements and stronger actions: knowledge checkKnowledge check · 14 questions
7. 7.Root cause analysis with 5 Whys and fishbone: causal statements and stronger actions: practical exerciseKnowledge check · 1 question
8. 8.Final exam10 questions · passing it completes the course, so people who already know the material can test out

Sources it draws on

The lessons and questions are written from these references, so learners can go back to the original.

• AHRQ PSNet: Root Cause Analysis (primer, last reviewed 15 June 2024)
• IHI: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm (tool page)
• National Patient Safety Foundation: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm (version 2, January 2016)
• IHI Patient Safety Essentials Toolkit: Action Hierarchy (part of RCA2) (2019)
• IHI Patient Safety Essentials Toolkit: 5 Whys: Finding the Root Cause of a Problem (2019)
• IHI Patient Safety Essentials Toolkit: Cause and Effect Diagram (2017)