Root Cause Analysis to Improve Jail Safety: Getting Past Blame
This toolkit is intended to introduce, or re-introduce, the concept of root cause analysis (RCA) to help jail leaders assess both current risk management and prevention strategies. Whether faced with examining a critical incident, or being proactive in addressing emerging issues, RCA is a viable instrument. Waiting for a “spectacular” incident before examining operations is an irresponsible way of doing business. The consequences of error may be perceived as minor. For example, an inmate in court misses her medication; to tragedy, if that missed medication was a pattern that contributed to a negative medical outcome. Failure to collect, analyze and act on data itself creates or magnifies harm and safety risks.
This toolkit is intended to help jail leaders create and instill methods for assessment of current processes before, during and after incidents.
This toolkit includes: