Use of RCA in health

A review of the existing literature has identified no papers directly addressing the validity of RCA in adverse-event investigation in health or in psychiatry. Most authors have focused on the lack of evaluation of effectiveness of RCA in health, especially with reference to recommendations and action plans,^{Reference Taitz, Shumack, Burrell, Kennedy, Genn and Brooks12,Reference Stavropoulou, Doherty and Tosey17–Reference Latino22} which are the output of RCAs. Several authors have considered whether RCA is the best method to investigate adverse events in health.

One of the earliest reviews questioning the widespread and somewhat uncritical adoption of RCA as the investigative methodology of choice for adverse events in healthcare was by Wu et al (2008).^{Reference Wu, Lipshutz and Pronovost18} They argued that although RCA had been adopted widely in the USA, there had not been an evaluation of its effectiveness in healthcare. Their focus was on acute hospital-based medicine and they noted that at the time there were no studies in the peer-reviewed literature of the effectiveness of RCA to reduce risk or improve patient safety, nor were there evaluations of cost-effectiveness compared with other tools to mitigate hazards. The authors noted that there were no nationally agreed definitions of adverse events, reporting requirements, guidance for conducting these investigations, or a central process for quality assurance of reports or monitoring of the implementation of recommendations or actions.

They also noted the resource-intensive nature of RCA, with each investigation taking 20–90 person-hours to complete. They acknowledged that the investigation of an adverse event in medicine based on RCA is best suited to incidents related to medical devices and manufactured products, such as medicines, and less so for problems related to performance and communication. They concluded that there was lack of evidence of effectiveness, utility and cost-effectiveness of RCA, and recommended that RCA be evaluated for effectiveness and utility in healthcare. However, the authors did not address the issue of validity, nor the use of RCA in mental health services.

In a review of use of RCA in acute hospital-based medicine, Trbovich et al (2017)^{Reference Trbovich and Shojania23} contended that because of wide variation in the quality of investigations and recommendations of RCAs, they inevitably failed to explore ‘deep system problems’, resulting in recommendations and corrective actions primarily aimed at changing human behaviour rather than system-based changes.

The authors noted that critical incidents arise from the interplay between active failures and latent conditions, and investigations and corrective actions should focus on latent conditions that make active failures more likely. They noted that RCA teams tend to focus on the first causal factor identified, rather than considering these factors as part of a sociotechnical system (i.e. the interaction of people and technology embedded in an organisational structure), thus leading to recommendations and corrective actions that do not address fundamental problems. They emphasised the importance of identifying effective corrective actions that are aligned to causal factors, acknowledging the reluctance to identify solutions requiring substantial financial resource.

Referencing James Reason, who developed the ‘Swiss Cheese model’ of error causation,^{Reference Reason24} they characterised the goal of error investigation as ‘draining the swamp, not swatting mosquitoes’. The authors concluded that making system improvements is difficult and expensive, but to realise the promise of RCA, health systems had to be prepared to fund teams with expertise in human factors and safety signs.

This review did not address the issue of validity or the differing issues in mental health services. The authors acknowledged the inherent limitations of a retrospective analysis of this type, including hindsight bias; the difficulty of ascertaining to what extent contributing factors actually caused the adverse event; and other factors that may have been missed, especially those that shape behaviour, such as task complexity and flawed workflow, which enabled the adverse event to occur. They also noted the lack of evidence of effectiveness and recognised that recommendations and actions do not seem to improve safety.

Kellogg et al (2017)^{Reference Kellogg, Hettinger, Fairbanks, Shah, Wears and Sellers25} carried out a quantitative and qualitative retrospective analysis at a single acute hospital in the USA. They examined 302 RCA investigation reports completed over the previous 8 years, specifically the summary description of the incident, recommendations and action plans to determine a taxonomy of solution-types proposed by RCA teams. They found that the most common proposed solution types were training, process change and policy reinforcement, all of which are potentially weak solution types, as these failed to address the most basic premise of safety engineering involving sociotechnical systems, which is that human errors will always be repeated, and it is therefore the system that needs to adapt.^{Reference Carayon, Hancock, Leveson, Noy, Sznelwar and van Hootegem11,Reference Rasmussen26} Solution types such as technology changes and institutional-level changes, which are more effective in bringing about sustainable change, were not proposed as frequently. The authors argued that this was evidence of the lack of effectiveness of RCA.

They concluded that the current approach of healthcare systems to RCA was contributing to failures in improving patient safety, and that RCA teams need guidance on solution types in order to improve the effectiveness of RCA. However, the authors did not include mental health services in their review and focused on identifying ways of improving the effectiveness of RCA by providing guidance to RCA teams on developing better recommendations and action plans. They did not comment on the validity of RCA in healthcare.

Vrklevski et al (2018)^{Reference Vrklevski, O'Connor and McKechnie27} evaluated the use of RCA for investigating and responding to adverse events in a large metropolitan mental health service in Australia. Using a mixed-method approach, the authors examined 26 RCAs (linked to 21 suicides, 3 homicides and 2 deaths from other causes), focusing on the type of ensuing recommendations and the time to implementation. They found that recommendations were ‘weak’ in 71% of cases. Weak recommendations are those that require a change in human behaviour, which when used alone are unlikely to affect a sustained improvement in safety.^{Reference Hibbert, Thomas, Deakin, Runciman, Braithwaite and Lomax28} By contrast, strong recommendations in this context rely less on human behaviour and memory, and are likely to be effective and sustainable. The review found that only 65% of recommendations were implemented within 12 months, and no root cause was identified in 70% of incidents. They noted a lack of fidelity to the original RCA model, with much variability in how investigations were completed.

Semi-structured interviews with mental health staff who had completed RCA reviews were undertaken, to identify ways in which RCA processes could be strengthened: these found low engagement of clinicians in RCA, although participants felt that RCA was useful as it provided a formal, structured process to review adverse events. The authors noted that RCA is better suited to medical incidents that occur with moderate to high frequency, but less so for rare events or those that involve complex interactions of human variables that are difficult to control, such as homicides and suicides. They concluded that this investigation enhanced understanding of why recommendations from investigations on adverse events in mental health services are not always implemented, while acknowledging that 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. However, the authors did not comment directly on concerns relating to validity.

A review by Peerally et al (2017)^{Reference Peerally, Dixon-Woods, Carr and Waring13} identified eight challenges with the use of RCA in healthcare. The authors felt that RCA does have face validity in health, but did not specifically refer to validity in mental health services. They reflected that the name encouraged a flawed reductionist view by suggesting the existence of a single root cause or a small number of root causes. Like other authors, they too noted the significant variation in the quality of RCA investigations, and felt the lack of independence, need to preserve reputation, and resource and time constraints meant that the process was vulnerable to political highjack.

They noted the lack of effective recommendations arising from RCA investigations, leading to weaker solution types and failure to reduce recurrence and increase safety. Poor feedback to clinical teams involved was found to contribute to lack of double-loop learning methods needed for sustained improvement in safety. They noted the tendency for RCA investigations to remain within organisations, leading to lack of system learning; the temptation to assign blame to individuals or teams for the adverse events, and the difficulty of accounting for the role of many actors (human, process and environmental) that lead to an outcome. The authors concluded that RCA does have benefits in healthcare and considerable face validity, and made recommendations to improve its use.

Hagley et al (2019)^{Reference Hagley, Mills, Watts and Wu29} examined a number of alternatives to RCA. They identified seven methodologies, which included:

1. (i) after-action review;

2. (ii) adverse event debriefing and huddles;

3. (iii) learn from defect tool;

4. (iv) SWARM;

5. (v) concise incident analysis;

6. (vi) comprehensive frameworks for incident report investigation and analysis; and

7. (vii) aggregate RCAs and multi-incident analysis.

The authors provided a comparative analysis of these approaches with reference to the time taken for the tool to be administered and resultant improvement in safety.

The authors noted that the best methods to investigate adverse events remain unclear, as all tools have trade-offs, and that the appropriate investigative framework may vary depending on the context of the healthcare organisation.

This review^{Reference Hagley, Mills, Watts and Wu29} did not comment on the validity of any of these tools, which still fundamentally rely on some variation of RCA to identify why an adverse event occurred, and devise recommendations and actions based on identified causes. It was not specific to mental health services, and it is not clear whether any of the seven tools examined were used in mental health services.