The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services.
Approach to Improving Safety
Setting of Care
Root cause analysis is a longstanding approach to in-depth investigation of adverse events, with evidence supporting its use in identifying underlying causes of safety problems. Reviewing for mental health events, mostly suicides and homicides, researchers found that recommendations often echoed existing policy and were not implemented. While the authors assert that the method may not be helpful, their findings also emphasize the importance of implementing root cause analysis recommendations in order to augment safety.