An incident happens. A team investigates. Actions are agreed. Months later, the same incident happens again — same shape, different patient.

It recurs for one simple reason: the investigation found a cause, but not the root cause. Until the root cause changes, the incident will keep coming back.

Two traps I see again and again:

1. Stopping at the person. “Human error” is where most investigations end — but it is where they should begin. People work inside systems: workload, interruptions, handovers, equipment. Put a different person in the same situation and the same thing is likely to happen again. If your investigation ends with a name, it has not found the cause.

• A fix that treats the symptom. Retraining. A reminder. A memo. These help only if they match the real reason. A checklist helps when someone forgot a step — not when the step is buried in a form nobody can find.

So, map the causes first — people, process, equipment, environment, management, materials — the branches of a fishbone diagram. Then keep asking why. Each “why” moves you one step further from the person and one step closer to something you can actually change.

A good root cause analysis ends with three things: one root cause, stated plainly. One action that changes the system, not the person. And one named owner, with a date to check whether it worked. If the action is “be more careful”, it is not an action.

Incidents keep recurring not because healthcare workers don’t care — they care deeply — but because the system that produced the incident is still exactly as it was. Change the system, and the incident stops recurring.

STS Academia conducts classroom and online courses on RCA and FMEA if you wish to learn more. You can check us out at stsacademia.com

#PatientSafety #RootCauseAnalysis #HealthcareQuality #QualityImprovement #Healthcare #InfectionControl #Singapore

Sim Tianseng

STS is the principal trainer and founder of STS Academia, specializing in healthcare training in Infection Control, Quality, and Patient Safety. With over a decade of experience as the Chief Infection Control Officer at a leading private hospital group in Singapore and 10 years as an Adjunct Lecturer for Flinders University’s Master of Health Administration programme, He brings deep practical expertise to every course.He is committed to helping everyone, including healthcare professionals, build strong, evidence-based competencies they can apply immediately in their work environment.