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The causes of their death appear (unto our shame perpetual): Why root cause analysis is not the best model for error investigation in mental health services

journal contribution
posted on 2023-05-18, 21:52 authored by Lila VrklevskiLila Vrklevski, McKechnie, L, O'Connor, N

Objectives: Root cause analysis (RCA) is the model of accident investigation mandated by the New South Wales Ministry of Health in Australia to review all serious incidents. Anecdotal evidence suggests that the RCA model is not suitable for reviewing adverse events in mental health services such as suicides and homicides. The aims of the research were to evaluate the impact of RCA on improving patient outcomes in a regional mental health service in New South Wales, Australia, and to discover whether the RCA model is the most appropriate model in mental health.

Methods: The literature on RCA was reviewed. The effectiveness of implementation of RCA recommendations was evaluated using quantitative and qualitative data.

Results: Suicides and homicides, which constitute 90% of serious critical incidents in mental health, do not always lend themselves well to identification of a root cause. There is evidence for low clinician engagement in the recommendations that arise from RCAs and a poor level of evidence that implementation of RCA recommendations results in safer patient care. Most troubling is the finding that RCAs frequently make recommendations that repeat existing policy or previous recommendations.

Conclusions: Although the RCA model offers a formal and systematic approach to the review of serious critical incidents in mental health, it is not the model of best fit. Only 65% of recommendations made through RCA reviews are implemented within 12 months.


Publication title

Journal of Patient Safety










Lippincott Williams & Wilkins

Place of publication

United States

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Socio-economic Objectives

Preventive medicine

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