Root Cause Analysis (RCA) of adverse events in one of the biggest western Iranian general hospitals: Short communication

Pouran Raeissi, Aidin Aryankhesal, Niusha Shahidi Sadeghi, Hadi Kalantari

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Background: In developing and underdeveloped countries, medical error is often either not reported or reported improperly for various reasons. Root cause analysis (RCA) is a systematic method to determine how various factors contribute to the occurrence of medical errors.  

Objectives: The current study analyzed the root cause of one of western Iran's biggest general hospitals.  

Methods: This retrospective RCA was conducted through a qualitative approach in 2019 following the National Patient Safety Agency (NPSA) protocol in seven steps: Initialization of the process, collecting and mapping information, identifying issues related to care delivery problems (CDP) or service delivery problems (SDP), event analysis, identifying the involved factors in the event - root causes, providing solutions, implementing solutions, and submission of reports.  

Results: According to the results of this study, 61 cases were examined, and committees accepted the errors in 11 cases. Here, 49 CDP and 13 SDP factors were identified. Care delivery problems factors were selected for all events based on the team's viewpoints. Overall, task-related causes (20 cases), individual causes (17 cases), management-related causes (14 cases), training-related causes (8 cases), and causes related to work environment and conditions (7 cases) were specified.  

Conclusions: Accepting mistakes is the first step in the hope of improvement. In this hospital, only 11 cases of mistakes had been accepted by the authorities. In most cases, the proposed solutions to this issue included personnel training, monitoring system strengthening, and developing and standardizing processes. Overall, this study and other similar studies showed errors during service delivery and through service providers. 

Original languageEnglish
Article numbere118032
Number of pages7
JournalHealth Scope
Issue number4
Publication statusPublished - Nov 2022
Externally publishedYes


  • Root Cause Analysis
  • Patient Safety
  • Medical Errors
  • Hospital
  • Patient Harm
  • CARE

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