Department of Health

Clinical incident investigations - root cause analysis

Key messages

  • Root cause analysis focuses on system and process failures.
  • Serious incidents require a root cause analysis to identify the underlying causes of system failures.
  • Root cause analysis guides solutions for addressing safety system failures.
  • Investigations requiring root cause analysis should be initiated as soon as practical after an incident has occurred.

Root cause analysis (RCA) is a process analysis used to identify the underlying causes of system failures. It provides the information needed to solve problems and address these failures.

Clinical risk managers and other healthcare personnel use RCA to help them find answers to the questions posed by serious incidents. They investigate what happened, why it occurred, and what can be done to prevent it from happening again.

RCA investigations should be led by a trained facilitator.

When to undertake root cause analysis 

RCA is normally only performed on high-risk, high-impact events, such as sentinel events or incidents that have an incident severity rating of one (ISR 1).

The RCA process should not be performed for incidents involving criminal acts or requiring disciplinary action.

Timelines for root cause analysis

The RCA investigation process should be started as soon as possible after an incident has occurred.

  • An RCA team should be convened as soon as possible after the incident has occurred.
  • The RCA report should be signed off within two calendar months from the start of the investigation. 

The Department of Health & Human Services funds public hospitals and health services on the condition that they will:

  • notify the department of the occurrence of all sentinel events by completing the sentinel event notification form
  • submit to the department a report of the investigation’s findings and a risk reduction action plan (RRAP) within two calendar months from the start of the investigation. 

RCA investigation principles 

The key principles of a root cause analysis investigation are to:

  • focus on systems and processes, not individual performance
  • be fair, thorough and efficient
  • focus on problem solving
  • use recognised analytical methods
  • use a scale of effectiveness to develop recommendations.

Attributes of an RCA investigation

RCA investigations have four main attributes.

  • Thoroughness - a complete review of all possible causes is required.
  • Fairness - all staff members associated with the incident are required to participate.
  • Efficiency - the time taken to undertake the investigation should be consistent with the significance of the problem being investigated.
  • Independence - independent team members should be involved in the investigation to reduce the impact of bias and ensure impartiality.

Steps in the root cause analysis investigation

Defining the problem provides a clear understanding of the problem the RCA team is to address, the scope of the investigation, and the consequences of the incident.

The major steps in an RCA investigation are to:

  • verify the incident and define the problem
  • commission the RCA investigation
  • map a timeline (event and causal factor chart)
  • identify critical events
  • analyse the critical events (cause and effect chart)
  • identify root causes
  • support each root cause with evidence
  • identify and select the best ways of addressing the problem
  • develop recommendations
  • write and present the report.

Reviewed 11 November 2021

Health.vic

Contact details

Postal address: GPO Box 4541, Melbourne VIC 3001

Quality and Safety Branch Department of Health

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