Root Cause Analysis

A key requirement for safety focused health care organisations is to manage, report, analyse and learn from all patient safety incidents. It is no longer sufficient for health care providers to learn and improve only from things that go wrong. Using a proactive risk management approach, together with a reactive process of incident management will help in the identification of the things that COULD go wrong.

In addition to collecting and analysing information about serious incidents, individual organisations should identify less serious errors and, importantly, near misses. The objective of RCA is to identify root causes so that these latent failures may be eliminated or modified and future occurrences of similar problems or mishaps may be prevented. Robust reporting systems and in-depth root cause analysis enable learning from such local incidents, changes to deficient systems and procedures, sharing of experience, safer practice and more open, honest and just cultures.

Training programmes focus on:

• Problem solving not blame
• Systems and processes
• Human factors and limitations
• Links between cause and effect
• Identifying actual and potential failures
• Identifying underlying organisational causes
• Achieving consistent evaluations which reach the same level of causation
• Barriers to the elimination of the causes
• Practical approaches
• Action planning
• Effective communications

GAT RCA programmes provide participants with the skills and expertise to effectively apply the principles and techniques of root cause analysis in their working environment. A workshop approach is used to allow the participants to share information and experience. The syllabus includes:

• Human Factors and Teamwork
• What is Root Cause Analysis
• RCA Tools and Techniques
• The Error Chain concept
• Causal effects - systems and humans
• Mapping causal factors to the Error Chain model
• Identifying opportunities for breaking the chain
• Grading for impact and repeatability
• Identifying actions
• Strategies for gaining commitment
• Identifying the lessons learned
• Changing cultures

These courses are particularly applicable to clinical governance leads, risk managers, ward managers and practitioners involved in risk assessment training.