The process of completing a Root Cause Analysis can be useful in determining the factors which contributed to an incident and therefore can be valuable to efforts in addressing systemic issues. However, not all incidents require the methodology of a Root Cause Analysis to understand the contributing factors and underlying issues of an incident.  Many accidents, injuries, and deaths are attributable to individual and self-evident causes. In such cases the exercise of conducting a Root Cause Analysis will yield no new or useful information to the provider.

Additionally, there are incidents which occur where providers will not have the means to determine all or even some of the factors which contributed to the incident. This is likely to be the case for some Level III incidents which occur outside of the purview of the providers’ services and facilities.  In cases where providers are unable to accurately determine the factors which contributed to an incident it makes little practical sense to complete a Root Cause Analysis.

For these reasons we recommend that the regulations be revised to state that during their review of incidents providers will take reasonable steps to determine the underlying causes of Level II and Level III incidents.  The regulations can then highlight the utilization of Root Cause Analysis as a preferred method for determining the factors which contributed to incident This maintains the requirement that providers examine incidents to determine their root causes but offers greater latitude to providers regarding how they meet this requirement. In cases where the cause of an incident is obvious providers may not need to take additional actions and in cases where providers could not reasonably know the cause of an incident they are free from the obligation of conducting a fruitless Root Cause Analysis.