Root Cause Analysis Workshop (ISMP)


To provide a standardized approach to the retrospective analysis of critical incidents and near-miss events in health care, ISMP Canada, Saskatchewan Health, and the Canadian Patient Safety Institute worked together to develop a Canadian Root Cause Analysis Framework. The Framework has been updated in 2012 and is entitled Canadian Incident Analysis Framework. The Framework is an analytic tool for performing a system-based review of incidents, including but not limited to medication incidents. It utilizes well established methods for analysis designed to help determine the root causes and contributing factors that led to an event and to identify strategies for implementing system improvements.

The goals of root cause analysis are to determine

What happened?

How and why it happened?

What can be done to reduce the likelihood of recurrence and make care safer?

What was learned?

RCA often reveals underlying system deficiencies that are not obvious, as well as issues that have become so familiar to those working in a particular environment that they are not identified as risks. RCA does not assign blame and is outcome directed, with emphasis on specific, high-leverage actions that take into account human factors engineering principles and the need to design systems with integrated safeguards.

Canadian health care providers are gaining knowledge and understanding about the impact of underlying system factors and the latent conditions that can increase the risk of incidents. ISMP Canada shares learning from incident analysis in the ISMP Canada Safety Bulletins and newsletters and alerts for consumers.

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