A Root Cause Analysis is "a systematic process that allows for the identification and management of underlying factors and system vulnerabilities that contributed towards the occurence of an incident".
How is a Root Cause Analysis Commenced
All incidents that rate as SAC 1 (very high or extreme risk, including reportable events) require a RCA in accordance with the Queensland Health Incident Management Implementation Policy and Clinical Incident Management Implementation Standard. The Patient Safety Officer (PSO) will discuss the incident with the District Chief Executive Officer (CEO) and seek approval to commence an RCA. Approval is given by the District CEO on an official RCA Commission Document.
Root Cause Analysis (RCA) Teams
All Root Cause Analysis are conducted utilising a team approach. The quality of the RCA Final Report composition and effort. Team help to maintain objectivity and reduce the risk of bias often encountered when one person completes the review.
How is the team formed?
The District CEO (with support/advice from the PSO) will select the team for the RCA to ensure that the members of the team meet the criteria described below. The team members' names are clearly documented on the RCA Commissioning Document. The PSO will then seek approval from the individuals and relevant line managers to ensure that the people selected are available and committed to the process.
No RCA should commence without a signed and completed RCA Commissioning Document.
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