Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a structured, system‑focused method for investigating adverse events, near‑misses and process failures.
Its purpose is to explain how and why an incident occurred, identify contributing and root causes (often multiple), and convert those findings into time‑bound, measurable actions that reduce the risk of recurrence.
RCA should support learning rather than blame and aligns with national patient‑safety expectations and statutory reporting duties (NICE; Resuscitation Council UK).
Purpose and scope RCA aims to:
- Define the problem in operational and patient‑centred terms (what happened, who was affected, when and with what consequence).
- Identify system and process failures (latent conditions and active errors) rather than focus on individual blame.
- Produce prioritised, measurable recommendations with named owners, deadlines and verification measures.
- Feed lessons into local governance, education, audit and organisational learning.
RCA is reserved for incidents that indicate system‑level failure or significant harm; routine minor errors are usually managed through local improvement cycles. Local Trust reporting policies set specific thresholds and timescales and must be followed in parallel (NICE).
When to perform a full RCA (typical triggers) Consider a full RCA when an incident meets one or more of these criteria:
- Death or severe harm attributable (wholly or partly) to care in the department.
- Unexpected deterioration with significant harm.