Why Root Cause Analysis is not working
James Reason once characterised the goal of error investigations as ‘draining the swamp, not swatting mosquitoes’. Critical incidents arise from the interplay between active failures (eg. not double-checking for allergies before administering a medication) and latent conditions (eg. workload).
Swatting at the mosquitoes of ‘not double-checking’ is a waste of time and resources, and a key reason for reoccurring problems. We want to drain the swamp of the latent conditions that make not double-checking more likely to occur. Too often, RCA teams focus on the first causal factor identified (eg. staff violation of the allergy-checking policy) rather than considering such factors together as parts of a socio-technical system (ie. interactions between people and technology, embedded in an organisational structure).
Across human services, Root Cause Analysis (RCA) is a key method for investigating critical incidents and developing recommendations for preventing future events. In practice, however, RCAs vary widely in terms of their effectiveness. RCAs often fail to explore deep system problems that have contributed to safety events due to the limited methods used, constrained time and insufficient financial/human resources to conduct in-depth RCAs.
Jumping to corrective actions based on a single case analysed using a single method (ie. staff recall of the event during interviews and methods) can hardly be regarded as a robust strategy for improvement. Participants may overestimate the importance of some factors, miss other important contributing factors altogether, implement changes that do not address the causal factors as intended and even introduce new risks.
Staff and organisations may also lack the mandate and resources required to develop and implement sophisticated and effective corrective actions. Consequently, corrective actions default to changing human behaviour rather than system-based changes.
This commentary lays out key reasons for RCA not fulfilling its potential. Challenging us to look at the requirements for RCA processes that would make a real difference, and question whether human services are set up to fulfil this potential.
All accessed: 24/09/23
Trbovich P, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Quality & Safety 2017;26:350-353. https://qualitysafety.bmj.com/content/26/5/350https://qualitysafety.bmj.com/content/26/5/350