Library resource guides: ANZCA and FPM CPD Program resources: Root cause analysis (RCA)

Guide index

Root cause analysis (RCA)

Structured method of analysing serious adverse events to identify active and latent errors.

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May be organised by department, unit, group, practice, or hospital.
Can be a review of aggregated incidents or single incident

Participate in a root cause analysis (RCA) organised by your department, unit, group, practice or hospital.
Investigate a particular issue - for example: operating room fires - involving: pre-reading, followed by a literature search, review of ANZCA Professional Documents and ANZCA Bulletins, and a review of patient records.
Perform an in-depth case review on an adverse event - for example: an airway emergency involving patient mortality
Undertake an RCA and produce an RCA statement or report
Undertake an RCA looking at modifiable factors following a severity rating 1 incident

CPD Value: CPD participants may claim this under the Practice evaluation - measuring performance root cause analysis (RCA) activity.

External resources

SA Health: Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a method of investigating incidents. The purpose of a Root Cause Analysis investigation is to identify system issues that contributed to or resulted in the incident occurring and to provide recommendations for measures to prevent a reoccurrence of a similar incident.
Vic Health: Clinical incident investigations - root cause analysis
Root cause analysis (RCA) is a detailed and thorough investigation performed for sentinel events or critical incidents with a severity rating of 1.
Vic Health: Clinical incident investigations - root cause analysis(RCA) statements and reports
Root cause analysis statements show cause-and-effect relationships of an incident, and make recommendations to reduce the risk of an occurrence.

Best Practice Guide to Clinical Incident Management. 2e by State of Queensland (Department of Health) The Best Practice Guide to Clinical Incident Management has been developed as a statewide resource to support Queensland Health staff responsible for, or involved in managing, analysing and learning from patient safety incidents in healthcare settings.
Publication Date: January 2023
Clinical Incident Management Toolkit by Clinical Excellence Division, WDepartment of Health Western Australian The toolkit and resources are accurate at the time of publication. Please check the WA health CIM website and links in the further resources and templates for any updated processes or templates since the time of this publication.
Publication Date: 2019
Incident Management Guide by Australian Commission on Safety and Quality in Health Care (ACSQHC) his guide provides the healthcare workforce a concise overview of the incident management process and its underlying principles. It consolidates best practice approaches based on literature reviews and the Australian states’ and territories’ incident management policies.
ISBN: 9781922563309
Publication Date: 2021
Root Cause Analysis Toolkit (Serious Adverse Event Review) by NSW Government Clinical Excellence Commission This toolkit provides guidance for teams undertaking a root cause analysis (RCA) review. It includes the tools and processes that will assist a team in answering the three questions. The tools and templates have been adapted from the root cause analysis and action (RCA2) methodology1.The RCA Workbook [link] acts as a compendium to this toolkit and should be used by teams to ensure that all necessary steps have been completed.
Publication Date: 2020
Root Cause Analysis Workbook for Teams (Serious Adverse Event Review) by NSW Government Clinical Excellence Commission The Root cause analysis (RCA) workbook has been developed to support RCA teams to complete all of the necessary steps of the review process. It contains instructions and templates for the team to work through during each of their meetings. This document acts as compendium to the Serious adverse event review: Root cause analysis toolkit. Teams are encouraged to consult the toolkit for additional guidance.
Publication Date: 2020

Title: Root Cause Analysis
This recorded webinar provides an overview of the steps required to complete a root cause analysis for serious incidents in NSW Health.
Duration: 11 mins approx.

NSW Government Clinical Excellence Commission: Root Cause Analysis Podcasts

External courses

ACHS: Root Cause Analysis
Understand the policy and legislative requirements of undertaking a Root Cause Analysis. Develop skills in conducting the RCA process.
The Knowledge Academy: Root Cause Analysis - New Zealand
Learn systematic problem-solving techniques for RCA. Understand underlying issues causing complex problems. Gain skills to prevent recurring issues with our Root Cause Analysis Training.

CPD Value: CPD participants may claim this under Knowledge and skills short format learning activity.

ANZCA & FPM resources

CPD Activity Guide
This guide contains a list of all the activities associated with the ANZCA and FPM CPD Program, as well as links to associated individual activity guides and forms.

ANZCA: Literature Searching Library Guide
Learn more about how to conduct your own literature search and the ANZCA library's literature search service.
ANZCA: Journals
ANZCA Library subscribes to 1,100+ full-text journals, with access to an additional 10,100+ open-access and legacy e-journals.
ANZCA: Safety & Quality Resources Library Guide
This guide contains resources and information to complement those on the ANZCA Safety & Advocacy website. It includes a list of relevant college professional documents (policies, position statements, guidelines).
ANZCA: Safety & Advocacy Hub
This hub brings together resources related to safety, standards of practice - including anaesthetic incident reporting (webAIRS), critical incident debriefing, advocacy, and indigenous and global health, including those resources available through the ANZCA library.
ANZCA: Professional documents and statements
Our professional documents, statements and guidelines are crucial for promoting the safety and quality of patient care for those undergoing anaesthesia for surgical and other procedures and for those receiving pain medicine treatment.