Using the App

Root Cause Analysis Simulator

Premium tool. Open from /training-dashboard → Root Cause Analysis card (the dashboard uses the short label, without the "Simulator" suffix), or directly at /root-cause-analysis.

Every NHS pathology service runs Root Cause Analysis (RCA) on serious incidents. This simulator drills the two most common RCA methods in a fixed sequence: Fishbone, then 5-Whys, then the CAPA.

What it does

• Presents a serious incident scenario (e.g. wrong-result reported, sample mix-up, equipment failure leading to delay)
• Walks you through the Fishbone analysis, then the 5-Whys chain, then the CAPA
• Tests whether your identified root cause survives "the test" — would the same incident recur if your CAPA is implemented?
• Generates an RCA report PDF laid out to ISO 15189:2022 section 8.7 (nonconformities and corrective actions)

Methods covered

5-Whys

Linear cause-chain — ask "why?" five times to drill from symptom to root cause.

Example: "The blood gas came back wrong" → "because the analyser was out of cal" → "because the daily QC was not done" → "because the night shift was understaffed" → "because the rota didn't account for sickness" → ROOT CAUSE: rota policy lacks sickness buffer.

Fishbone (Ishikawa)

Categorical analysis across six axes — 6Ms:

• Manpower (people, training)
• Method (procedure, SOP)
• Machine (equipment)
• Material (reagents, samples)
• Measurement (QC, EQA)
• Mother Nature / Milieu (environment)

Useful when the cause is multifactorial.

Bowtie (not in the simulator)

Some Trusts also use bowtie analysis, which combines cause analysis with consequence mitigation. The simulator does not include it, but the teaching notes describe it because interviewers may ask.

Standards alignment

• NHS England Patient Safety Incident Response Framework (PSIRF) — current model, replacing the old SI framework
• ISO 15189:2022 clauses on nonconformities and corrective action
• NPSA / NHS Improvement historical guidance now under NHS England
• NICE quality standards where applicable
• MHRA Yellow Card integration for device-related causes

CAPA output

Each completed RCA generates:

• Corrective Action — what fixes this specific case
• Preventive Action — what prevents recurrence
• Verification of effectiveness — how you'll know it worked
• Owner and target date

CAPAs are central to ISO 15189:2022 compliance and to UKAS audit defence.

Bands and competency mapping

• Band 5 — participate in RCAs in your area
• Band 6 — lead RCAs for your section
• Band 7 / 8 — chair RCAs, present to Trust patient-safety committee, PSIRF lead

The RCA Simulator pairs with the EQA Investigation Training (article 42) and Incident Reporting Simulator (article 49). Cite the report PDF in your IBMS Specialist Portfolio quality evidence; real RCAs from your own laboratory remain the primary evidence.