Root cause analysis is a tool that can be used when determining how and why an adverse incident has occurred. Incidents that usually require a root cause analysis include an unexpected death, serious pressure ulcers, falls that result in injury, and some infections and medication errors.

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

Crucial questions in a root cause analysis are; what happened? How did it happen? 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.

While many root cause analysis tools can be used by a single person, the outcome generally is better when a group of independent people work together to find the problem causes. Those ultimately responsible for removing the identified root cause(s) should be prominent members of the analysis team that sets out to uncover them.

Having an external team complete an RCA for your care service is beneficial, as a fresh pair of eyes are better positioned to be able to provide an unbiased accurate report, and to embed a process which minimises the risk of adverse incidents occurring in the future.