Summary: A peer-reviewed article identified limitations and opportunities to implementing root cause analysis (RCA) in healthcare settings. RCA issues include political hijack, poor risk controls and feedback loops, and failure to aggregate learning across incidents. Effectiveness could be improved by providing greater visibility in the process and sharing lessons learned within and across organizations.
Excerpt: “Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents, is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events, RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science used to establish how and why an incident occurred, in an attempt to identify how it and similar problems might be prevented.
RCA is a promising approach with considerable face-validity as a way of producing learning from things that have gone wrong. However, too often, RCA results in the tombstone effect: though its purpose is to guard against a similar incident in the future, it may instead function primarily as a procedural ritual, leaving behind a memorial that does little more than allow a claim that something has been done. For healthcare to become a learning system, the opportunities and limits must be realized: RCA is a promising incident investigation technique borrowed from other high-risk industries, but has failed to live up to its potential in healthcare; A key problem with RCA is its name, which implies a singular, linear cause; Other problems include the questionable quality of many RCAs, their susceptibility to political hijack, their tendency to produce poor risk controls, poorly functioning feedback loops, failure to aggregate learning across incidents and confusion about blame and responsibility; Implementation and evaluation of risk controls to eliminate or minimize identified hazards need to become a more visible feature of the RCA process; Lessons learned from incidents, descriptions of implemented risk controls, and their effectiveness need to be shared within and across organizations.”
Value: Conducted as part of a comprehensive quality management approach, RCA can reveal targets for process improvement, and thereby improve safety, boost quality, and reduce cost. However, RCA is frequently adopted ineffectively or inappropriately, resulting in scapegoating, political backlash, and wasted effort. Conducting effective RCA requires an overarching quality management framework; cultural acceptance of “no-blame” faultfinding approaches; and professional expertise to collect and analyze data, synthesize multiple sources, and integrate the findings with a body of organizational lessons. A key to effective RCA in healthcare is to perform it as part of an integrated quality process that focuses on the clinical value chain, identifies risks, issues, and opportunities in key activities, and uses the output of RCA to identify and prioritize targets for quality improvement interventions.