ICS: Management Support Tools

Root Cause Analysis

Peter Bamford

Patient safety is one of the core principles of NHS working practice, with thousands of
patients treated successfully every day without incident. Occasionally however, adverse
events do occur and it is our responsibility as health care professionals to investigate why
they happen, so they might be prevented from recurring in the future.

Root Cause Analysis (RCA) is a problem-solving tool used to identify how and why patient
safety becomes compromised by a specific incident. It is unique in that it uses a specific
methodology to delve deeper into the events surrounding an incident so the root cause
can be identified. A factor is considered to be a root cause if its removal from a sequence
of events would prevent a final undesirable event from occurring. So rather than look at
the symptomatic results of a problem, RCA attempts to address the hidden failings of a
system or process.

Adverse events often have more than one root cause. This is because for every process
there are numerous interrelated actions that culminate to produce a final outcome. To
perform a RCA, all of these actions should be identified, which will enable the investigator
to trace back through a process and detect the root cause of the problem. An RCA
investigation will hopefully identify all the root causes associated with a problem to ensure
there is no recurrence of the problem. Once recognised the causes will often be the result
of:

 Physical factors where a material item has failed in some way

 Human factors where someone did something wrong, or failed to do something.
 Organisational factors where a system, process or policy used by an organisation as
the basis for decision making is faulty

Why do we do RCA?

The incorporation of RCA into heath care systems lagged behind many other industrial
sectors. Having been initially developed by Sakichi Toyoda of Toyota Industries in the late
1950’s, it wasn’t until the late 1990’s when a study demonstrated that death from medical
errors was the 8th leading cause of death in America, that there was a move to identify a
more systematic approach to identifying preventable errors. RCA has since become the
preferred mechanism for health care risk management and has provided institutions a way
of bringing about necessary improvements to patient safety.

When to do an RCA?

The NHS in conjunction with National Patient Safety Agency, have produced guidance on
what events should trigger the initiation of a RCA. These include:

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 Incidents occurring where there is National Guidance on the issue.

 Frequently occurring incidents
 Significant/Systemic service failure
 Issues which attract pubic/media concern
 Any incident which could have resulted in severe or death as an outcome
 Homicide/Suicide by a patient in receipt of mental health care programme
approach in the last 6 months
 Any potentially avoidable death on healthcare premises

There are a few specific circumstances where adverse events should not be investigated
with an RCA, and should instead be referred to the appropriate body e.g. Police
 Events thought to be the result of a criminal act by care providers/staff
 Purposefully unsafe (malicious) acts by care providers intending to cause harm
 Acts related to substance abuse by care provider/staff
 Events involving suspected patient abuse of any kind

Once it has been decided that an RCA should look a specific incident, it must also be
decided what level of investigation should be performed and who will be responsible for
carrying out and facilitating the process. The table below outlines briefly what should be
expected for each level of investigation.

Level 1(Concise) Level 2 Level 3(Independent)

(Comprehensive)
When should it Incidents which Incidents which Incidents with high level
be used? resulted in no, low resulted in of media interest or
or moderate harm mental health homicides
Who should Conducted by local Conducted by MDT not Conducted by people who
investigate? staff, should involved in incident, are independent to the
incorporate a who have experience provider service or
person with in RCA. Should be organization
knowledge of RCA supported by
process and the facilitator
patient if involved.
Analysis 5 Whys High level of detail. High level of detail Full
Fish Tail analysis Full use of analytical use of analytical tools
tools
Report Often released as Full report with Full report with summary
summary document summary including including
and includes plans recommendations for recommendations for
for shared learning sharing locally and sharing locally and
locally and/or nationally nationally
nationally

Processes involved in RCA

Although the methodology used to perform RCA may differ between institutions there are
certain steps that should be followed to ensure the process is systematically completed.
Failure to complete all of these steps could result in a failure to identify the root cause
of the incident and the potential for recurrence would remain. The steps outlined below
are the minimum requirements for completion of an RCA.

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Identify
Contributory
Collect Data
Factors and
Root Causes

Recommend
Define
& Implement
Problem
Solutions

System of
Vigilance RCA Write Report

Vigilance and Reporting:

RCAs are reactive processes, performed retrospectively after adverse events have
occurred. It is therefore essential that institutions employ a robust and continuous method
of monitoring clinical activity; so critical incidents can be reported in a timely fashion.

Define the Problem:

Factually describe and document the event before disseminated a summary to all
investigators. This will ensure the team, are clear about the issues they are investigating

Collecting data:
Gather all the relevant information to the incident, this may include:
 Staff statements/reports or the finding of interviews
 Retrospective clinical records
 MDT reviews
 Timeline of events leading up to the incident
 Copies of relevant documents such as Trust policies/clinical guidelines that apply
to the incident

Identify possible causal factors and root causes:

There is no defined methodology for performing an RCA, with various different techniques
having been developed to satisfy the needs of specific industries. Common methodologies
employed in healthcare are the 5 Whys method and Cause and Effect Analysis which are
described below

5 Whys Method:
By repeatedly asking the question “why” the investigators drill down through a problem until
they reach a point where all of the issues are fully understood, i.e. the root cause of the
problem is ascertained rather than the symptoms of the failure. The method relies on the
process of defining the problem, then brainstorming as to why the problem has occurred. If

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the answer is unlikely to be the root cause, the process is repeated until the investigators
are happy they have fully understood the problem and identified the potential hidden root
cause.

The benefits of the method are that it not only helps to identify the root cause of a problem,
but also if there are a number of causes, the potential interaction between the different
causes. It is also relatively simple to perform, requiring no statistical analysis.

Cause and Effect analysis:

Cause and Effect diagrams combine brainstorming with mind mapping to explore all
the possible causal factors before attempting to find a problems solution. Again the

Patient Individual Task Communication Team factors

factors (staff) factors factors
factors

Problem
or issue
(CDP/SDP)

Education Equipment Working Organisational

& Training & condition & strategic
Factors resources factors factors

problem under investigation is defined before spines are drawn from the diagram,
which identify the major factors for consideration (See above). Then for each of the
factors the investigators brainstorm the possible causes of the problem related to
that area. Finally the diagram is analysed to establish which branches relate to the
root cause.

Recommend and implement solutions

Recommendations should address all root causes identified by the process and
concentrate specifically on reducing the likelihood of recurrence. Solutions should
be Specific, Measureable, Achievable, Realistic and Timed (SMART), they should
also be categorized as either specific to the area where it happened, those common
to the organization, and those that are universal to all e.g. National significance.
There are a number of tools e.g. Barrier analysis & Impact analysis and which can
be utilized to assess whether an intervention will be effective. Once implemented

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it is also vital that the strategies implemented are observed in operation to ensure
their effectiveness in tackling the original problem.

Writing a report:

The purpose of the report is to provide:

 A formal record of the investigation process
 A means of sharing the learning from the case

The report should explain:

 What happened
 Who it happened to
 When it happened
 Where it happened
 How it happened? What went wrong?
 Why it happened? What root cause analysis was identified
 What recommendations have resulted from the investigation
 How will they be implemented

References:

Root Cause Analysis (RCA) Toolkit – National Patient Safety Agency

The NHS Institute for Innovation and Improvement website
Root Cause Analysis, Tracing a problem to its origin – Mindtools.com