Root cause analysis
Resources
- Checklist Flip Chart
for Root Cause Analysis Teams (PDF 109KB)
This resource was not developed by the Department of Health. The Patient Safety Directorate in no way endorses, recommends or guarantees the efficacy of the resources on this website. It is the responsibility of health services and health service staff to use the resources as a guide only. - 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)
- Clinical Incident Management Toolkit for other investigation methods. (PDF 2.4MB)
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.
File Formats
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