​The most common solutions offered by root-cause analysis (RCA) also tend to be the least effective at reducing event recurrence, according to an April 19, 2017, study in BMJ Quality and Safety. The authors reviewed 302 reports on RCAs conducted between 2001 and 2008 at a large academic medical center. Patient death was involved in 36.7% of the RCAs. Across 106 RCAs, 731 solutions were proposed. The most commonly proposed solutions were training (20% of the time), process change (19.6%), and policy reinforcement (15.2%). These were also found to be weaker actions, least likely to decrease recurrence of the events. This was supported by the fact that even after the RCA team performed repeated examinations of retained foreign body events, the events continued to occur throughout the study period. Although some events are impossible to eliminate, the authors said, they believe that the recurrences were associated with the quality and types of solutions that the RCA team offered. Systems-based changes have been found to be the most effective way to mitigate risk in other industries, the authors said, but these have not yet become the standard for healthcare. More effective methods, such as culture change and equipment redesign, were highlighted in an accompanying editorial. A commentary in the same issue outlined several problems with current RCA processes, such as poorly designed risk control, poorly functioning feedback loops, and confusion about blame. The authors listed a list of limitations to the RCA process, including the term itself, "which implies a singular, linear cause," and its susceptibility to political influences.

HRC Recommends: How RCAs are performed and the mindset of the organization and the RCA team determines whether RCAs successfully lead to improvement in patient safety. Investigators may inappropriately focus too intently on the details of the process or the individuals involved, resulting in the identification of seemingly apparent "causes" that are in reality effects of something deeper, and recommending only interventions that seem readily achievable (i.e., "easy solutions"). The work and resources spent on an investigation and RCA are wasted if deeper organizational issues are not unearthed in the process or if the actions taken as a result of the RCA do not address them. Further, when systems issues are left unaddressed, adverse events and other organizational problems can result. The HRC materials linked in "Related Resources" can help risk managers get the most out of the conduct of RCAs and implement a comprehensive approach to system safety to prevent foreseeable accidents and to minimize harm from unforeseen ones.