Department of Health

Key messages

  • Root cause analysis (RCA) statements must be written as ‘cause and effect’ statements.
  • An RCA report must include a risk reduction action plan.
  • RCA reports identify risks and recommend solutions that are communicated to health service management.

Root cause statements are written as conclusions. Conclusions can be either ‘cause and effect’ statements or prophetic statements - that is, predictions showing a probable ‘cause and effect.’

Five rules of causation

When describing why a sentinel event or serious incident has occurred, statements must:

  • show the ‘cause and effect’ relationship or clear link between the root cause and the undesirable outcome
  • not use negative descriptors (and avoid inflammatory statements)
  • show that for every human error in the causal chain there is a corresponding condition cause that contributed to the undesired effect
  • identify the preceding cause of a procedural deviation or violation, not the violation
  • describe a failure to act as causal only when there is a pre-existing duty to act, and when it arises from standards and guidelines for practice, or other duties to provide care.

Preparing recommendations and reports

The root cause analysis (RCA) team should consider which personnel they will need to consult when developing recommendations. The team must also be aware of the wider system implications of actually putting recommendations in place.

To be credible, recommendations should be evaluated against the:

  • root cause or conclusion statement
  • level of associated risk
  • hierarchy of control / scale of effectiveness
  • achievability
  • perceived value to the organisation. 

Writing a root cause analysis report

The purpose of writing the RCA report is to communicate to management the findings, conclusions and recommendations pertaining to the initial incident. The significance of the investigation’s findings will determine the comprehensiveness of the report.

The report is written after recommendations have been evaluated for effectiveness and should include:

  • an executive summary
  • an event map
  • a cause and effect chart
  • conclusions and supporting evidence
  • recommendations.

Developing the risk reduction action plan

A risk reduction action plan (RRAP) is developed from the causal statements of an RCA report. This should be made in conjunction with staff responsible for organisational risk management, and requires an assessment of the level and analyses of the risk.

The RRAP should include a description of:

  • who is accountable for the risk
  • what action is to be taken
  • who is responsible for the action
  • when the action is to be completed
  • a measurable performance target. 

RCA reports are to be endorsed by the health service clinical governance committee to ensure the identified risks and solutions (of these risks) are communicated to the health service executive and board of management. 

Document maintenance 

Keeping an RCA investigation register provides a record of the investigations undertaken. It must include details of when they were conducted, what problem/s were solved, and which staff members participated. 

Keeping a copy of all completed reports, RRAPs and achieved outcomes is necessary in case a similar problem occurs. In this instance the health services will be able to identify previous effective and ineffective strategies. 

Documenting risk reduction action plans in a risk register or other action tracking system is necessary to ensure the monitoring and outcome loop is closed. 

Post-investigation responsibilities 

The RCA facilitator or program coordinator has responsibility for presenting the investigation’s findings to the people involved in the incident, ensuring organisational reporting requirements are met, and completing the department’s reporting requirements.

The sponsoring executive is responsible for ensuring an RRAP is prepared and implemented, and the progress and outcomes of risk mitigation strategies are monitored.

Reviewed 11 November 2021


Contact details

Postal address: GPO Box 4541, Melbourne VIC 3001

Quality and Safety Branch Department of Health & Human Services

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