Don’t be misled by the notion of a “root cause”, which is implied in root cause analysis. The root cause is that issue, thing or person that is thought to be fundamental to the occurrence of an incident. If you fix that – or those, as there may be more than one root cause – then the incident won’t recur.

That’s the principle. But in practice, as the example showed, it might be difficult to work out when you are looking at the root cause as opposed to some incidental issue. Also, even if you were able to pick out a root cause, that might not be the thing that should be focused on for remediation and instead looking at another issue that might have more impact despite being downstream or upstream is required.

It’s for this reason that the London Protocol does not place as much emphasis on finding root causes, and instead recommends looking a bit more broadly at the range of contributory factors that might be present and interact with each other to create an incident, possibly in ways that are not immediately obvious.

Once you've completed this module, move onto:
Part three: Safety culture
Part four: Reporting and analysis
Part five: Patient and public involvement
Part six: Huddles
Part seven: Making improvements to patient safety
Part eight: The second victim phenomenon
But be sure to click next to complete this module first.