How do you conduct an RCA in healthcare?

Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis.

Root causes are the fundamental issues that led to the occurrence of an incident and can be identified using a systematic approach to investigation. Contributory factors related to the incident may also be identified.

Crucial questions in a root cause analysis are: what happened? How did it happen? And why did it happen?

Undertaking a root cause analysis can assist in identifying areas for change and developing recommendations, with the aim of providing safe patient care.

Reflective activity

‘How to’ articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:

A patient safety incident that has occurred in your clinical practice, such as the unexpected death of a patient, a fall that resulted in injury, a serious pressure ulcer, an infection or a medication error. What happened next? Was a root cause analysis undertaken and what was the outcome of this?

How you can support your colleagues to undertake a root cause analysis after a patient safety incident occurs.

Nursing Standard. 32, 20, 41-46. doi: 10.7748/ns.2018.e10859

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We use a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls.

The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. Because our Culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function. We focus on the "how" and the "why" ? not on the "who". Through the application of Human Factors Engineering (HFE) approaches, we aim to support human performance.

Because people on the frontline are usually in the best position to identify issues and solutions, RCA teams at VA health care facilities formulate solutions, test, implement, and measure outcomes in order to improve patient safety.

The VA RCA Process

The goal of an RCA is to find out:

• What happened
• Why did it happen
• How to prevent it from happening again.

The RCA process is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.

In an RCA, basic and contributing causes are discovered in a process similar to diagnosis of disease - with the goal always in mind of preventing recurrence.

The RCA process is: 

• Inter-disciplinary, involving experts from the frontline services
• Involving of those who are the most familiar with the situation
• Continually digging deeper by asking why, why, why at each level of cause and effect.
• A process that identifies changes that need to be made to systems
• A process that is as impartial as possible

To be thorough an RCA must include: 

• Determination of human and other factors
• Determination of related processes and systems
• Analysis of underlying cause and effect systems through a series of why questions
• Identification of risks and their potential contributions
• Determination of potential improvement in processes or systems

To be Credible an RCA must: 

• Include participation by the leadership of the organization and those most closely involved in the processes and systems
• Be internally consistent
• Include consideration of relevant literature

Learn More

A detailed review of VA's RCA process:

The Patient Safety Improvement Handbook provides detailed information on how and why VA conducts RCAs, plus much more. VA patient safety reports, such as RCAs, are confidential under 38 U.S.C. 5705.

The Safety Assessment Code (SAC) can be used to determine whether or not an RCA must be conducted, based on the severity of a specific incident and its probability of occurrence.

A "SAC score" is also of value for incidents that did not result in an adverse event but may also lead to an RCA; i.e., a close call. Close calls occur far more frequently than adverse events and can provide an exceptional opportunity for learning. Close calls afford the chance to develop preventive strategies and actions before a patient may be harmed.

The SAC Matrix is a tool for combining severity and probablilty. While either the severity or probability of occurrence could be determined first, it is usually more productive to assess the severity first.

A wide range of related information is available by scrolling through our Glossary of Patient Safety Terms.

A number of articles have appeared in our newsletter, TIPS, which discuss the RCAs and the RCA process, such as:

Published Articles

Numerous NCPS staff members, past and present, have coauthored articles that concern a wide of range of issues that involve RCAs.

What are the steps in conducting RCA?

What are the 5 steps of RCA?

What are the 6 steps of RCA?

Which are the steps to perform a root cause analysis in healthcare?