Have you ever been part of a root cause analysis that didn't seem useful, or, worse yet, didn't really get to any of the true root causes? Healthcare colleagues, the British Medical Journal of Quality & Safety recently highlighted your pain exactly. Look here. RCAs are incredibly useful tools that need to be performed just so, and they are not without their weaknesses. For advanced tips on the use of RCAs (specifically the fishbone/Ishikawa diagram you typically build during an RCA), look here.
Constrained by strict timelines, and skewed by hindsight bias and lack of independence from the organisation where the event took place, RCAs in healthcare often end up a compromise between ‘depth of data and accuracy of the investigation’. The quest to complete an investigation on time and produce a report risks goal displacement, where the report is seen as the end product rather than the beginning of a learning cycle. Reports themselves, influenced by the need to preserve interpersonal relationships and by hierarchical tensions and partisan interests may not always reflect the content of discussions during investigations nor the realities of what happened.