Root Cause Analysis (RCA) is a method of ‘drilling down’ to investigate adverse events in order to assist in the identification of health system flaws that may not be immediately apparent at initial review.

It is a technique developed by the US Veteran’s Health Administration (US-VHA) for the identification of contributing system factors in health related adverse events and near misses.

During an RCA causal statements are generated through event mapping and investigation of links between context, events, actions and patient outcomes.

The characteristics of an RCA are:

• a focus on systems and process – not individual performance
• a review of literature
• a means of extensive examination of the events in order to uncover underlying contributing factors
• the potential to lead to procedure and system change. This can occur through system redesign or the introduction of a new process to prevent recurrence
• causal statements indicating the cause and effect of the event
• causal statements which do not use negative language or focus on human error without a preceding cause
• an interdisciplinary approach – staff on the RCA team have knowledge about the event and the process of care
• a primary focus on systems – staff dig deeper asking ‘what’ and ‘why’ until all aspects of the event are reviewed and contributing factors are considered
• an environment that is safe from blame and retribution

The unit provides RCA training throughout the year.