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Frequently Asked Questions #5. What is the difference between a proximal cause and a root cause, and why have you said that you dislike both terms? Allow us to offer a two-part response. First off, a "proximal cause" or "proximate cause" is an obvious one. In an example we commonly use in teaching, if a physician orders a medication with a consequent, direct adverse effect, a proximal cause is human error on the part of the physician. He or she made an apparently wrong decision. But the "root cause" may be, for example: the physician was required to work for too many hours and was understandably fatigued because of unreasonable work demands, he or she had a cognitive impairment which should have been identified by credentialing activity, there were inadequate automated checks and balances in the pharmacy order entry system, the nurse who followed the order did not feel that he or she had sufficient authority to question the order, prior alternatives had failed and the "inappropriate" medication order was an novel treatment with a reasonable literature base performed, with full patient and family informed consent, and after consultation with an expert experienced in that treatment, the nurse wanted to "get back" at the physician for a personal affront and therefore intentionally did not take action to prevent the adverse consequence, the situation was emergent, and a coexistent medical condition precluded the safer alternatives, while the order did not reflect an optimal clinical decision, the dosage administered was in excess of the order, compounding the severity of outcome, etc. The root cause or causes thus represent the underlying system as opposed to personal or individual contributions to the untoward event. Why do we dislike the terms "proximal cause" and "root cause?" The term "cause" implies, obviously, causation. In health care there are many situations wherein it is a unique combination of circumstances which leads to an adverse event, and no single or even pair of "causes" are necessary and sufficient to bring about the event. The circumstances increase the likelihood of the adverse outcome, and are thus contributory in nature, rather than causative. We therefore prefer to use the term "contributory factor" rather than "root cause." We will use the term "root cause" because it is accepted terminology, but we will emphasize ad nauseum (for which we apologize) the foregoing distinction. As an additional consideration, in litigation there may be a significant distinction between a jury's emotional response to "root cause" versus "contributory factor" or "root contributor."      Root Cause Analyst Software® | FAQs on the Issues | Root Cause Analysis Training Cost-Effective Root Cause Analysis | Root Cause Analysis Software - Article Resource Links | Guestbook | About MRMA | Email MRMA  Sponsored by Medical Risk Management Associates, LLC HRM Consulting and Software Development Specialists Copyright© 1998, 1999 MRMA, LLC. All rights reserved. All other trademarks are the sole property of their respective owners. Page last modified 20 October 1999.