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Root Cause Analysis (RCA) investigation

Every day a million people are treated safely and successfully in the NHS. 

However, when incidents do happen, it is important that lessons are learned  to prevent the same incident occurring elsewhere. Root Cause Analysis investigation is a well recognised way of doing this.


Investigations identify how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for our patients.  

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Contact us:

The investigation unit developed by the National Patient Safety Agency (NPSA) has now transferred to NHS England. Our new email address is: england.RCAinvestigation@nhs.net


RCA Investigation Training

Training in RCA investigation is no longer available from the NPSA or NHS England. Alternative training providers may be sourced from an internet search. The training materials developed by the NPSA will be available shortly via the link below. When copying, publishing, distributing, transmitting, adapting or exploiting these materials you must acknowledge the source by including an attribution statement such as: 

  • 'Content developed by the National Patient Safety Agency'

  • 'Adapted from material developed by the National Patient Safety Agency'


                                                           RCA investigation presentations - NPSA 2011 


RCA investigation resources

The following resources have been developed to support widespread good practice in RCA investigation.