How to undertake a root cause analysis investigation to improve patient safety
Evidence & Practice    

How to undertake a root cause analysis investigation to improve patient safety

Elizabeth Haxby Lead clinician in clinical risk, Royal Brompton Hospital, London, England
Caroline Shuldham Independent consultant and chair of the RCNi Editorial Advisory Board, Surrey, England

Rationale and key points

Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis.

Root causes are the fundamental issues that led to the occurrence of an incident and can be identified using a systematic approach to investigation. Contributory factors related to the incident may also be identified.

Crucial questions in a root cause analysis are: what happened? How did it happen? And why did it happen?

Undertaking a root cause analysis can assist in identifying areas for change and developing recommendations, with the aim of providing safe patient care.

Reflective activity

‘How to’ articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:

A patient safety incident that has occurred in your clinical practice, such as the unexpected death of a patient, a fall that resulted in injury, a serious pressure ulcer, an infection or a medication error. What happened next? Was a root cause analysis undertaken and what was the outcome of this?

How you can support your colleagues to undertake a root cause analysis after a patient safety incident occurs.

Nursing Standard. doi: 10.7748/ns.2018.e10859



Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Conflict of interest

None declared

Contributing to the How to series

To suggest a ‘How to…’ article, please email with a synopsis of your idea


This ‘How to’ guide is available at: For related articles search the website using the keywords


Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence

*On 1 April 2016 the statutory patient safety functions previously delivered by NHS England transferred with the National Patient Safety Team to NHS Improvement

Received: 02 March 2017

Accepted: 16 October 2017

Published online: 05 December 2017

Want to read more?

Subscribe for unlimited access

Try 1 month’s access for just £1 and get:

Your subscription package includes:
  • Full access to and the Nursing Standard app
  • The monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal
RCN student member? Try Nursing Standard Student
Already subscribed? Log in

Alternatively, you can purchase access to this article for the next seven days. Buy now