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The 5 Rules of Causation

The 5 Rules of Causation

After system vulnerabilities have been identified by the RCA2 team, it’s time to document and write them for others to see and use to make improvements. Causal statements are written to describe (1) cause, (2) effect, and (3) event. Something (cause) leads to something (effect) which increases the likelihood that the adverse event (event) will occur.

Here’s an example: A high volume of activity and noise in the emergency department (cause) led to the resident being distracted when entering medication orders (effect) which increased the likelihood that the wrong dose would be ordered (event).

When the five rules below are met, causal statements will be more compelling, increasing the likelihood that corrective actions will be supported.

Source: Adapted from The Five Rules of Causation developed by the Department of Veterans Affairs, Veterans Health Administration, and appearing in their NCPS Triage Cards for Root Cause Analysis and their document Root Cause Analysis (RCA), The five rules were adapted from the Federal Aviation Administration technical report “Maintenance Error Causation,” by David A. Marx, June 9, 1999.