Enhancing root cause analysis with simulation: A safety II approach to clinical governance
Root Cause Analysis (RCA) is a valuable tool in healthcare for identifying systemic factors that contribute to errors. However, its traditional deterministic approach often focuses on finding a single root cause, typically human error, which can limit its effectiveness in preventing future adverse events. This narrow focus is compounded by hindsight bias, where the outcome influences how past decisions and actions are judged. As a result, conventional RCA can inadvertently damage organisational culture by attributing blame instead of addressing system-level issues.