Vrklevski Lila Petar, McKechnie Leanne, OʼConnor Nick
J Patient Saf. 2018 Mar;14(1):41-48. doi: 10.1097/PTS.0000000000000169.
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.
The literature on RCA was reviewed. The effectiveness of implementation of RCA recommendations was evaluated using quantitative and qualitative data.
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.
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.
根本原因分析（RCA）是澳大利亚新南威尔士州卫生部规定的事故调查模式，用于审查所有严重事件。轶事证据表明，RCA模式不适用于审查心理健康服务中的不良事件，如自杀和杀人事件。本研究的目的是评估RCA对改善澳大利亚新南威尔士州一个地区心理健康服务中患者结局的影响，并探究RCA模式是否是心理健康领域最合适的模式。
对RCA的相关文献进行了综述。使用定量和定性数据评估了RCA建议的实施效果。
自杀和杀人事件占心理健康领域严重关键事件的90%，并不总是易于找出根本原因。有证据表明临床医生对RCA提出的建议参与度较低，且几乎没有证据表明实施RCA建议能带来更安全的患者护理。最令人担忧的是，RCA经常提出重复现有政策或先前建议的建议。
尽管RCA模式为审查心理健康领域的严重关键事件提供了一种正式且系统的方法，但它并非最适合的模式。通过RCA审查提出的建议中，只有65%在12个月内得到实施。
