This issue's CE article, authored by Dr. Joyce Black, reviews a fundamental method for identifying and describing variances in performance, root cause analysis (RCA). As Dr Black points out, RCA is particularly well suited to pressure injury prevention. In its simplest formulation, RCA enables clinicians to systematically describe and analyze policies, care delivery, and related processes, along with provider- and patient-related factors that contributed to a variance in an unanticipated outcome (occurrence of a pressure injury).

The purpose of this commentary is not to reiterate the insights and lucid explanation of RCA provided by Dr Black. Rather, I wish to emphasize that RCA, or one the alternatives to this techniques for quality improvement such as Lean or Six Sigma, are an essential model for WOC professional practice. I also wish to call out and dispel what I perceive as the most persistent myth of RCA; it exists to assign blame and sanction rather than a framework for quality improvement. As Dr Black points out in her lucid article, identification of the cause of a variance in anticipated outcome requires application of a model, such as the Ishikawa (fishbone) model described in her article. She also identifies specific factors that may explain why a full-thickness pressure injury occurred: location (eg, differentiation of a sacral pressure injury in an immobile patients vs an occipital ulcer in a patient undergoing spinal surgery) and probable time of onset (eg, an injury present or evolving at the time of admission vs a pressure injury that developed after a prolonged period immobilized before admission or during transport to hospital). She discusses system-wide factors contributing to a pressure injury including leadership support, existing policies, availability of resources such as pressure-redistributing mattresses or specialty beds, and staff education.

Dr Black acknowledges several limitations of RCA, including the lack of linearity of some pressure injury occurrences, restrictions when applying an individual occurrence to larger care system, and difficulty achieving sufficient distance from those delivering care and those evaluating variances in patient outcomes. I would add another limitation to application of RCA, the persistent myth that its true goal is assigning blame or sanctions when a negative outcome occurs, rather than proactively seeking solutions to improve care processes. Dr Black alludes to this myth when she describes common cause analysis and the value of combining several RCA analyses, but I believe it deserves further consideration.

Root cause analysis reminds me of the uncomfortable, but essential process surgical departments such as the one I practice in must complete on a regular basis, a review of cases where unanticipated complications occur. When I first presented a case that I participated in the care of a patient reviewed at an "M&M" review, I felt a combination of fear and dread that I would be singled out for criticism and sanction. Instead, I experienced a detailed review of events, constructive suggestions for alternative approaches to my care, and a communal attitude that care is strengthened by reviewing negative outcomes and working together to seek solutions. As a critical player in the RCA process, you have an opportunity to form alliances with key players overseeing this essential quality improvement process in order to reject any temptation to use the process merely to lay blame. Instead, I urge you to focus on the true goal of quality improvement, creating an environment of communal learning and challenge that results in sustainable improvements in care rather than recurring variances in care that occur because they are not acknowledged or critically examined.