Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a method or methodology used to investigate an incident in order to assist in the identification of health system failures that may not be immediately apparent at initial review. The purpose of an RCA is to identify system issues that contributed to or resulted in the incident occurring and to provide recommendations on actions to be taken to prevent or minimise a recurrence of a similar incident. It is interdisciplinary in nature and uses a structured process which endeavours to answer three questions:
- What happened?
- Why did it happen?
- How can it be prevented from occurring again?
An RCA is not used to apportion blame to staff; it is designed for learning and improving the quality of the health system.
Part 8 of the Health Care Act and protection from disclosure
If an incident meets the definition of an adverse incident which appears in the Government Gazette, an RCA may be done under Part 8 of the Health Care Act 2008. In which case the information gained during the RCA is protected from disclosure
If the information gained during the RCA process is to be protected under Part 8 of the Act, a number of legislated requirements must be met. If all requirements are not met then information gained during the investigation will not be protected from release. An overview of these requirements is provided in the document conducting a root cause analysis (PDF 135KB) which should be viewed in tandem with the Health Care Act 2008 (SA) and the Health Care Regulations 2008.
Root Cause Analysis (RCA) is a method or methodology that is used to investigate an incident in order to assist in the identification of health system failures that may not be immediately apparent at initial review. The Root Cause Analysis Policy Directive (PDF 673KB) provides guidance to ensure that when an RCA is conducted under the protection of Part 8 of the Health Care Act 2008 (SA) (the Act) all legislative requirements are met.
- Tool 1 - Root Cause Analysis (RCA) Reports and Documentation Requirements (PDF 115KB)
- Tool 2 – Contributing Factors Classification (PDF 94KB)
- Tool 3 – RCA Flipchart (PDF 159KB)
- Tool 4 - Letter to Appoint a Root Cause Analysis Leader (DOC 120KB)
- Tool 5 - Letter to Appoint a Root Cause Analysis Team (DOC 120KB)
- Tool 6 - RCA Agreement (team leader) (DOC 353KB)
- Tool 7 - RCA Agreement (team member) (PDF 209KB)
- Tool 8 - Information for interviewees (PDF 77KB)
- Tool 9 – Report 1 Template (PDF 47KB)
- Tool 10 – Report 2 Template (PDF 72KB)
- Tool 11 – RCA Checklist (PDF 130KB)
- Tool 12 - Frequently asked questions about Root Cause Analysis (RCA for patients/consumers, families, carers and/or support persons (PDF 80KB)
The leader of a RCA team must have completed a formal RCA training course.
Root Cause Analysis final reports
On completion of an RCA, the investigating team is required to prepare two reports:
- Report 1 (DOC 62KB) is a public report that contains:
- a description of the adverse incident, based on facts known prior to the investigation
- recommended changes or improvements.
- Report 2 (DOC 63KB) a protected report that contains:
- a description of the adverse incident
- a causation statement
- the recommendations of the RCA team
- any other material considered relevant by the RCA team.
These reports should be finalised within 70 calendar days of the RCA being commenced unless a formal extension has been granted.
Further information about documentation requirements is provided in Root Cause Analysis (RCA) Reports and Documentation Requirements (PDF 115KB).
RCA training is available for clinical and administrative staff across SA Health. For more information see the RCA training page.
SA Health Safety and Quality Unit
Senior Project Officer
Telephone: (08) 8226 6035