Root cause analysis
Resources
- Checklist Flip Chart for Root Cause Analysis Teams (PDF 109KB)
- Clinical Incident Investigation Standard (PDF 51KB)
- Root Cause Analysis Guidelines (PDF 36KB)
- Root Cause Analysis Investigation Form (PDF 76KB)
- Root Cause Analysis Investigation Form (Word 74KB)
What is a root cause analysis?
Root Cause Analysis (RCA) is a comprehensive and systematic methodology to identify the gaps in hospital systems and the processes of health care that may not be immediately apparent and which may have contributed to the occurrence of an event.
Root cause analysis:
- Focus on systems and processes, not on individual performance
- Examine extensively for underlying contributing factors and root causes
- Identify changes that could be made to improve systems and processes to prevent re-occurrence of similar events
- Find safer, more efficient ways to deliver patient care
Purpose of a root cause analysis
The purpose of an RCA is to develop recommendations and actions for the organisation to implement to reduce the risk of sentinel events occurring in the future. An RCA will try to answer the questions:
- What happened?
- Why did it happen?
- What can be done to prevent it from happening again?
Who is responsible for conducting a root cause analysis?
RCA investigations are conducted by multi-disciplinary teams who seek to determine the root causes of the incident and provide recommendations about how to avoid such incidents reoccurring. Individuals in each health service have been trained in the RCA methodology and may assist with the investigation. Contact us for a list of RCA trained clinicians. Alternatively, consultants from the Office of Safety and Quality in Healthcare are available to guide hospitals and health services with the RCA process.
The Office of Safety and Quality in Healthcare runs regular one-day workshops to train health service workers in RCA investigation. The workshop schedule for 2008 is currently being developed. For more information contact us.
File Formats
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