Conducting RCAs PDF

Root cause analysis (RCA) and
Risk reduction action plans (RRAP)

Clinical risk management (CRM)
What is an RCA?
RCA is a process analysis method, which can be used to identify the factors that cause adverse events. 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.
Risk managers and other health care personnel use RCA analytical methods to investigate (‘drill down’ into)
serious incidents (including near misses) to identify the underlying causes and to guide solutions to address
safety system failures.
When should RCA be undertaken?

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 (ISR1) in the Victorian health incident management system (VHIMS). The
RCA process should not be performed for incidents involving criminal acts or requiring disciplinary action. The
Victorian health incident management policy and policy guide outline the relationship between process and
analysis method in detail, these can be accessed at http://www.health.vic.gov.au/clinrisk/vhims/.
What are the timelines for RCA?

The RCA investigation process should be instigated as soon as practical after an incident. The more time
elapsed, the less reliable the account of events by people involved and important information might no longer be
available.
 A RCA team should be convened as soon as practical to the incident occurring.
 The RCA report should be signed off within 2 calendar months of commencing the investigation.
Public hospitals and public health services are funded by the Department of Health on the condition that they
will:
 notify the department of the occurrence of all sentinel events by completing the sentinel event notification
form
 report the investigation findings and risk reduction action plan within 2 calendar months to the Department
of Health.
RCA investigation principles

The main principles of a RCA investigation are to:
 focus on systems and processes, not individual performance
 be fair, thorough and efficient
 focus on problem solving
 use recognised analytical methods
Department of Health

 use a scale of effectiveness to develop recommendations.
Attributes of a RCA investigation

The four major attributes of a RCA investigation are:
1. thoroughness: a complete review of all possible causes is required
2. fairness: in terms of involvement of all staff associated with the incident
3. efficiency: the time taken to undertake the investigation should be consistent with the significance of the
problem being investigated
4. independence: including independent team members will reduce the impact of bias and overcome the fear
of having to present information others might not want to hear.
Major steps in a RCA investigation

The major steps in a RCA investigation are:
1. verify the incident and define the problem
2. commission the RCA investigation
3. map a timeline (event and causal factor chart)
4. identify critical events
5. analyse the critical events (cause and effect chart)
6. identify root causes
7. support each root cause with evidence
8. identify and select the best solutions
9. develop recommendations
10. write and present the report.
Defining the problem provides a clear understanding of:
 the problem the RCA team is required to address
 the scope of the investigation
 the consequences of the incident.
Writing root cause statements (conclusions/casual statements))

Root cause statements are written as conclusions. Conclusions can be either:
 cause and effect statements
 prophetic statements (predictions).
An example of each is given here.
Cause and effect:
The lack of staff training on the management of patients with chest pain resulted in the patient being discharged
without appropriate investigations being completed, which contributed to the patient’s readmission and
subsequent cardiac arrest
Prophetic:
The unavailability of guidelines for the management of chest pain in the emergency department will continue to
contribute to the delivery of sub-optimal care.
Page 2, August 2011 Department of Health

The five rules of causation

1. Causal statements must clearly show the ‘cause and effect’ relationship. When describing why an event
has occurred, show the link between the root cause and the undesirable outcome.
2. Negative descriptors are not used in causal statements. To force clear cause and effect descriptions (and
avoid inflammatory statements) do not use negative descriptors.
3. Each action cause must have a corresponding conditional cause. For every human error in the causal
chain, there must be a corresponding condition cause that combined to contribute to the undesired effect.
4. Each procedural deviation must have a preceding cause. Identify the cause of a procedural violation, not
the violation.
5. Failure to act is only causal when there was a pre-existing duty to act. The duty to perform might arise from
standards and guidelines for practice or other duties to provide patient care.
Preparing recommendations and reports

The RCA team will need to consider who to consult when developing recommendations and be aware of the
wider system implications of actually putting recommendations in place.
To be credible, recommendations should be evaluated against:
• the root cause (conclusion) statement
• the level of associated risk
• the hierarchy of control / scale of effectiveness
• achievability
• the perceived value to the organisation.
Writing a RCA report

Reports are written to communicate to management the findings, conclusions and recommendations pertaining
to the initial problem the RCA team were requested to investigate. The report is written after recommendations
have been evaluated for effectiveness.
The report should include the following elements:
1. executive summary
2. event map
3. cause and effect chart
4. conclusions, supporting evidence
5. recommendations.
The report’s comprehensiveness depends on the significance of the investigation findings.
Developing the risk reduction action plan

The causal statements developed in the RCA investigation need to be converted into risk statements. This
should be done in conjunction with staff responsible for organisational risk management. It requires an
assessment of the level and analyses of the risk.
The risk reduction action plan should include a description of:
• who is accountable for the risk
• what action is to be taken

• who is responsible the action

• when the action is to be completed by
• a measurable performance target.
Completed RCA reports should be endorsed by the health service overarching clinical governance committee.
This ensures identified risks and the treatments of these specific risks are communicated to the health service
executive and board of management.
RCA document management

Keeping a RCA investigation register will provide a record of the investigations undertaken, when they were
done, what problem they were commissioned to solve, and which staff participated.
Keeping a copy of all completed reports, risk reduction action plans and the outcomes achieved is necessary in
case a similar problem occurs and the organisation needs to identify which strategies were ineffective.
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-RCA investigation responsibilities

The RCA facilitator/program coordinator has responsibility for:
• arranging for the findings to be presented to the people involved in the incident
• ensuring organisational reporting requirements are met
• completing Department of Health reporting requirements.
The sponsoring executive is responsible for:
• ensuring a risk reduction action plan is prepared and implemented
• monitoring the progress and outcomes of risk mitigation strategies.
For more information

For more information visit the CRM website at http://www.health.vic.gov.au/clinrisk/index.htm

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What is RCA and when should it be undertaken?

What is RCA and when should it be undertaken?

What are the major steps in a RCA investigation?

What are the major steps in a RCA investigation?

Root cause analysis (RCA) and

Risk reduction action plans (RRAP)

When should RCA be undertaken?

What are the timelines for RCA?

RCA investigation principles

 use a scale of effectiveness to develop recommendations.

Attributes of a RCA investigation

Major steps in a RCA investigation

Writing root cause statements (conclusions/casual statements))

Page 2, August 2011 Department of Health

The five rules of causation

Preparing recommendations and reports

Writing a RCA report

Developing the risk reduction action plan

Page 3, August 2011 Department of Health

• who is responsible the action

RCA document management

Post-RCA investigation responsibilities

For more information

Page 4, August 2011 Department of Health

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