Using Root Cause Analysis to Instill a Culture of Self-Improvement: Program Replication Materials

Document Type

Article

Publication Date

4-2015

Abstract

This white paper describes an internal Root Cause Analysis (“RCA”) conducted by the Montgomery County, PA District Attorney’s Office (“DA”) in partnership with the Quattrone Center for the Fair Administration of Justice, an interdisciplinary research and policy center within the University of Pennsylvania Law School (“Quattrone Center”). The Quattrone Center specializes in RCA regarding errors within the criminal justice system. RCA has been used in complex and fragmented industries (e.g., healthcare, aviation, nuclear power) to understand the various factors (direct and environmental) that lead to both individual and systemic-based errors, and to provide interventions that can effectively prevent future error.

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