SynthesisMedical principles and practice : international journal of the Kuwait University, Health Science Centre2020
How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review.
Synthesis in Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 28 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
28 citing papers in PubMed, 1 synthesis or guideline pooled it, 70 citations in OpenAlex.
- Quality Upper Gastrointestinal Endoscopy in Australia and Aotearoa New Zealand: A Joint Position Statement.Journal of gastroenterology and hepatology · 2025Guideline
- From Evidence to Value: Integrating Evidence-Based Medicine, Patient Safety, Quality Improvement, Learning Health Systems, and Value-Based Healthcare.Journal of evaluation in clinical practice · 2026Review
- Establishing Patient Safety Cells in Public Tertiary Care Hospitals in India: A Practical Implementation Framework.Cureus · 2026Article
- From Root Cause Analysis to Systems Thinking: A Comparative Content Analysis of Patient Safety Incident Investigation Reports in Mental Healthcare.Journal of evaluation in clinical practice · 2026Article
- Perioperative patient safety: nurses' safety perceptions and observed compliance with safety standards in the operating room.BMC nursing · 2026Article
- Clinical Risk Management and Postoperative Outcomes After Colorectal Resection: A Retrospective Observational Study.Journal of personalized medicine · 2026Article
- Rethinking learning from incidents in healthcare: a Safety-II model integrating work-as-imagined, work-as-done, and work-as-experienced.Frontiers in health services · 2026Article
- Exploring a root cause analysis team's experience with involving patients and next of kin after a sentinel event.Frontiers in health services · 2026Article
- Assessment of the occurrence of adverse events through the global trigger tool in a university hospital in Italy.Scientific reports · 2025Article
- Decades of failure to prevent harm to patients-where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally.Frontiers in health services · 2025Article
- Hospital managers' experiences of conducting a root cause analysis: a case study following a sentinel event.Frontiers in health services · 2025Article
- Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study.BMJ open · 2024Article
- Quality indicators in respiratory therapy.World journal of critical care medicine · 2024Review
- Root cause analysis of safety incidents in antineoplastic use in children.Revista brasileira de enfermagem · 2024Article
- From Reporting to Improving: How Root Cause Analysis in Teams Shape Patient Safety Culture.Risk management and healthcare policy · 2024Article
- Medical errors can cost lives.Archives of medical science : AMS · 2024Article
- Intervention to improve adverse event reporting in the emergency department: Protocol of a systematic review and meta-analysis.PloS one · 2024Article
- Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.BMC health services research · 2023Article
- What are the experiences of team members involved in root cause analysis? A qualitative study.BMC health services research · 2023Article
- Dog breeds and conformations predisposed to osteosarcoma in the UK: a VetCompass study.Canine medicine and genetics · 2023Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors at 3 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesThe aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs).
methodsA systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies.
resultsTwenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs.
conclusionsRCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.