Articles and Case Studies

Root Cause Analysis

05 Oct 2015

Root cause analysis

Consider this scenario: The Director of Medical Services contacts you to advise that a Root Cause Analysis (RCA) will be conducted into the unexpected death of a patient, and that you are required to attend an interview with the RCA team.  

This article discusses:

  • the nature and purpose of RCAs
  • how to proceed if you are involved in a RCA.

What is Root Cause Analysis?

RCA is a systematic and comprehensive methodology to analyse systems and processes of care. The aim of a RCA is to identify areas of concern that may not be immediately apparent and which may have contributed to the occurrence of an incident. It focuses on the organisation of health care, rather than the assignment of individual blame.  

The goal of a RCA is to find out:

  • what happened
  • why it happened
  • what can be done to prevent it from happening again.


RCAs have the following characteristics:

  • The review is interdisciplinary in nature.
  • The review is undertaken by a small team (three to five people) who are familiar with the area in which the incident occurred, but not directly involved in the incident.
  • The analysis focuses primarily on systems and processes rather than individual performance.
  • The analysis identifies changes that could be made in systems and processes, through either redesign or development of new processes or systems that would improve performance and reduce the risk of recurrence.

The RCA team is required to determine the facts of what happened. In order to do so, information is gathered from a variety of sources, including interviewing and/or obtaining statements from those practitioners involved in the patient’s care and any witnesses to the incident. The RCA team is not permitted to investigate the competence of an individual doctor or other health practitioner.  

At the conclusion of the RCA process, the RCA team must provide a written report describing the incident, the reasons they think it occurred and any recommendations for change to practice or procedures. The final RCA Report is made available to a range of parties, including the patient and/or their family and the hospital administration.  

When is a RCA conducted?

Generally, a RCA is performed on serious adverse clinical events. RCAs may be mandated in certain circumstances – such as patient incidents with a severity assessment rating of one (serious events which are likely to recur) and sentinel or reportable events, e.g. maternal deaths or wrong site procedures.  

What should you do if you are asked to participate in a RCA?

You should initially review the relevant medical records and consider your direct involvement in the patient's care.  

If you are asked to attend an interview with the RCA team, it may be useful to prepare some notes to assist you during this discussion. Any notes should be marked as being “prepared for the purpose of a RCA”. You can bring a support person to the interview, if you wish to do so.  

If you are asked to prepare a report for the RCA team, again, this report should be clearly marked as being prepared for that purpose.  

If asked to participate in a RCA, Members are encouraged to contact our Medico-legal Advisory Services team for advice and support.  

Summary points

  • RCA is a process analysis method used to identify the factors that cause adverse events.
  • The focus of RCA is on system change, not the assignment of individual blame.
  • If you are asked to participate in a RCA, contact our Medico-legal Advisory Services on 1800 011 255 for advice.

Dr Sara Bird 
Manager, Medico-legal and Advisory Services 
MDA National

Complaints and Adverse Events, Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Practice Manager Or Owner, Psychiatry, Radiology, Sports Medicine, Surgery


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