Root Cause Analysis
Introduction and Overview
Undertaking a Root Cause Analysis (RCA) when a patient has a confirmed Health Care Associated Infection (HCAI), such as meticillin-resistant Staphylococcus aureus (MRSA), or Clostridium difficile infection (CDI), is an essential activity. A RCA should ensure organisations reduce the risk of a HCAI and provide safer care for future patients.
Working through the process allows organisations to understand areas requiring improvement in the patient care pathway, and more importantly, identifies and targets actions to minimise effectively the chance of recurrence. A clearly defined process embedded throughout the organisation is the key to a successful RCA.
We have developed a best practice process that outlines the specific stages we recommend that should be implemented to ensure robust RCA.
If you have any comments or questions, need further advice about using the toolkit, or suggestions about the RCA process or tools, email reducinghcai@dh.gsi.gov.uk
RCA Process
RCA Data Gathering Tools
The two data gathering tools below have been developed as excel workbooks. To ensure these tools are printed as a booklet, please select 'Entire Workbook' in the 'Print What' section when printing.
RCA Documents List
Click here for the RCA Training Documents List (PDF, 136.9 KB)
RCA Training Package
RCA Training Package Handouts
- Doc 2 - Train the Trainer Slides Without Notes (PPT, 1.7 MB)
- Doc 3 - Train the Trainer Slides With Notes (PPT, 1.8 MB)
- Doc 4 - RCA for Patient A Case Study (XLS, 159.7 KB)
- Doc 5 - RCA Action Plan for Patient A Case Study (PDF, 139.0 KB)
- Doc 6 - Root Cause Analysis (RCA) Process - Sections A, B, C, D and G - 9 September 2009 (XLS, 151.0 KB) also containing:
- RCA lead role profile
- RCA lead checklist
- Clinical team roles and responsibilities
- Rapid review checklist
- RCA review meeting roles and responsibilities
- Doc 7 - Evaluation Form (PDF, 156.7 KB)
- Doc 8 - Five Whys Tool (PDF, 197.5 KB)
RCA Training Delegate Pack
Patient A Case Study Folder
National RCA Presentations