Initially born from high-risk industries such as aerospace, aviation and nuclear power, the purpose of Root Cause Analysis is to facilitate learning from an undesired outcome to reduce errors. This methodology has been adopted by health care professionals as a tool for risk management.

What is Root Cause Analysis and what is its significance?

Root Cause Analysis (RCA) is a systematic and structured method used for retrospective analysis of adverse events (AEs) and sentinel events. This method goes deeper than surface symptoms. It looks for variations in practice, performance or system issues having led to the unexpected and undesired outcome. It helps us to systematically understand what went wrong, and how and why did the undesired outcome or incident happen.

RCA is one of the most commonly used quality tools for patient safety and standard of care improvements. Its purpose is to discover what, how and why an AE occurred, and answers the question of how can we prevent this incident from happening in the future.

Since RCA is evidence-based and considers relevant literature, it promotes a culture of patient safety and shifts the mindset from a possible blame culture to learning from undesired outcomes.

Despite numerous advances in the science of dental patient safety, there are times when patients do suffer unintentional harm during dental treatment. However, very little is known as to why and how they happen.

Not only can this systematic approach of RCA help us understand more about the incidents that could have been prevented, but it can also aid us in learning more about those that may trigger external investigations such as legal claims.

When is Root Cause Analysis performed?

A Root Cause Analysis is initiated when a patient suffers harm due to an incident during dental treatment or when an adverse event occurs. Adverse Events that may be suitable for RCA can be identified through patient feedback, direct observation by the provider or staff, reviewing patient notes or incident reports. The information acquired after the RCA can then be utilized to identify the root causes of the incident and to develop strategies for future prevention of such events.