Clinical risk management

Root cause analysis (RCA)

What is a RCA?

Root cause analysis (RCA) is a process analysis method, which can be used to identify the factors that cause adverse events.

When should a RCA be conducted?

A RCA should be conducted if an incident is identified that:

• reflects a national reportable sentinel event definition
• a valid clinical incident with a severity rating (ISR) 1 in Victorian health incident management system (VHIMS).

Purpose of a RCA

The RCA process is a critical feature of any safety management system because it enables answers to be found to the questions posed by high risk, high impact events—notably, what happened, why it occurred, and what can be done to prevent it from happening again.

It is believed that the frequency clinical incidents is likely to be reduced by examining the settings in which they occur, and identifying system changes required, which may reduce the likelihood of similar occurrences in the future.

This approach focuses on the organisation of health care, rather than the assignment of individual blame, and is therefore likely to promote a serious approach to error reduction at the health service level and is in keeping with the principles of accountability.

Conducting a RCA

The attached information sheet provides more information on conducting a RCA and developing recommendations:

 Conducting a RCA information sheet

The completed RCA should be documented on the RCA report template to complete the sentinel event reporting and investigation process.

When should RCA not be used?

The RCA methodology is not to be used for performance management related issues or any incident that is subject to review under the state or Commonwealth criminal justice system.