Root Cause Analysis (RCA) is a retrospective method of incident investigation that provides a structured approach to explore what happened; how it happened and why it happened. It then leads the investigator to determine areas requiring change, making recommendations and identifying sustainable solutions. 

It is possible to undertake RCA training as one or two day training events with the NPSA.  Alternatively, an on-line e-learning tool is available.  Many resources and templates are available as part of this package to guide you through a systematic incident investigation. Details can be found on the NPSA website.

Some Trusts have cascaded RCA training through their own organisations once a core of people have attended the NPSA training. It may be worth investigating this possibility through clinical governance / risk departments. Alternatively, you may find that your Trust will support individuals through an RCA with a member of staff who has attended the training.

Beware! RCA is a very complex and time-consuming methodology and should only be employed for the most complex patient safety incidents.  However, it provides an extremely useful format to follow and encourages you to examine beyond the obvious causes of incidents.

Maria M Roberts
Maria.Roberts@CardiffandVale.wales.nhs.uk