Root cause analysis (RCA), imported from high-reliability industries into health two decades ago, is the mandated methodology to investigate adverse events in most health systems. In this analysis, we argue that the validity of RCA in health and in psychiatry must be established, given the impact of these investigations on mental health policy and practice.

Six cases of serogroup C invasive meningococcal disease were identified in Treviso district, Veneto region, Italy between December 13 and 15, 2007. The afflicted patients were found to have attended the same Latin-dance clubs on the same nights, and chemoprophylaxis was provided to potentially exposed individuals. Despite these efforts, 2 cases caused by the same meningococcal strain subsequently occurred in the same area, without any apparent epidemiological correlation to the initial cases. This may have resulted from a failure to neutralize the meningococcal carrier/s. The root cause analysis method applied to public health emergency preparedness was used to analyze the response to this critical incident. The root cause analysis revealed a need to develop regional guidelines for the classification and management of a meningococcal outbreak and for developing risk-communication strategies that include the identification of appropriate channels of communication for differing segments of the population. (Disaster Med Public Health Preparedness. 2019;13:368–371)

To better understand the impact of early versus late design decisions, a study was undertaken on the root causes of missed requirements in new product development and their impact on development cost through rework activities. The context is the industrial development of unmanned aerial vehicles. The aim is to understand the occurrence rate of missed requirements, their root causes, and their relative impact. A quantitative approach of counting requirements changes and using engineering documentation enabled traceability from observation back to root cause origin. The development process was partitioned into sequential program segments, to categorize activities to before and after concept and design freeze. We found that there was a significant difference in the rate of design defects arising before and after concept freeze; and found there was a significantly higher number of corrective activities required for design defects arising earlier before concept freeze. The revision rate of concept phase decisions was over 50%, and the rework multiplier if detected late was over 10X. In combination, design decisions made before design freeze accounted for 86% of the total expected program cost, and 34% was determined before concept freeze. These results quantify and support the anecdotal 80–20 impact rule for design decisions.