Nurses are at the forefront of patient safety and are constantly reviewing their practice to improve care delivery. When things go wrong in health care the consequences can be distressing for patients and staff. Lessons need to be learned and acted on to minimise the likelihood of reoccurrence. The ‘root cause analysis’ approach provides nurses and other healthcare staff with a consistent and structured methodology to investigate incidents. It enables staff to identify where systems are failing and where improvements in patient care and safety can be made.