Objectives: Root cause analysis (RCA) is a framework for structured investigations of safety incidents. Our aim was to identify the barriers to successful learning in health care and to make recommendations for service development.
Methods: A qualitative study that 'tracked' the investigation procedures and practices of ten patient safety incidents in two National Health Service (NHS) hospitals. Non-participant observations of the complete investigation process in various managerial and administrative settings, together with semi-structured qualitative interviews with those involved in the process, and following the completion of the final report.
Results: There are several challenges to undertaking root cause analysis in health care. These are associated with forming and leading the investigation team; gathering and analysing supporting evidence; and formulating and implementing service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.
Conclusions: Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management.