Review of alternatives to root cause analysis: developing a robust system for incident report analysis

Medical errors and other system failures lead to patient injury and significant costs—estimates of potential societal costs range from $393 to $958 billion.1 2 To improve safety, the healthcare system has looked to industries with impressive safety records in high-risk contexts, often referred to as high reliability organisations (HRO), for ideas.3 In the 1990’s the Veterans Health Administration (VHA) adopted root cause analysis (RCA) from HROs to learn from the most serious incident reports (IRs).4 Over the ensuing decades, other healthcare organisations followed developing distinct, yet similar approaches.5–12 Systematic learning from IRs is a central component of reliable healthcare delivery systems. Methods to learn from IRs work best when they highlight areas of risk, which can lead to improved performance.12–19 Investigating IRs with RCA is consistent with the core characteristics of HROs. The structured feedback process on a defect in care provides the environment for organisational mindfulness. RCA ‘enables simultaneous adaptive learning and reliable performance’20 and promotes mindfulness by acting as ‘a window on the system’.21 However, it is neither feasible nor desirable to complete an RCA following every IR. For example, one 600-bed private hospital generates 15 000 IRs annually—an impossible number to investigate with RCA given that the process takes more than 20 person-hours and over $8000 to complete.22–24 Therefore, the RCA process is typically reserved for medical errors that lead to the greatest harm. Unfortunately, in the remainder of the cases, incident reporting alone does not improve safety.13 21 Thus, healthcare organisations need additional strategies to learn from no-harm and low-harm IRs that are rarely the subject of RCA.25 26 One example of a harmful IR that would lead to an RCA is a medication error that contributed to a patient death. On the other hand, if a nurse …