Lifting the lid on root cause analysis: A document analysis

Background: Root Cause Analysis (RCA) has been applied as a structured analytical technique to investigate patient harm events in Queensland Health since 2005; however, no research has been conducted on the text of RCAs across clinical services. Methods: A document analysis was conducted on original RCA reports from 2009, 2010, and 2011. Strict legislative conditions existed and de-contextualised text comprised the data. Analysis: The function of the RCA as a systematic process of analysis was masked by language decoys that saw relevant cause and effect information circumvented or ignored. Thus, latent organisational issues were not sufficiently identified and causality was disconnected from solutions. Active failures dominated the RCA due to a lack of systemic process of analysis. Conclusion: The RCA does not conform to dominant theoretic work on patient safety, or to legislative and policy objectives. A systems approach is compromised because creative methods inform the RCA.