Citation

Vrklevski LP, McKechnie L, O'Connor N. J. Patient Saf. 2015; ePub(ePub): ePub.

Affiliation

From the *Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, New South Wales, Australia; †Sydney South West North Coast Psychiatry Training Network, Sydney South West Area Health Service, Concord, New South Wales, Australia; ‡School of Medicine, Discipline of Psychiatry, University of Sydney, Camperdown, New South Wales, Australia.

Copyright

(Copyright © 2015, Lippincott Williams and Wilkins)

DOI

10.1097/PTS.0000000000000169

PMID

25815644

Abstract

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.

Language: en