Root Cause Analysis in Healthcare
Patient care, like other technically complex and high-risk services, is an interdependent process carried out by teams of individuals with advanced technical training who have varying roles and decision-making responsibilities. While technical training assures proficiency at specific tasks, it does not address the potential for error deriving from communication and decision making in dynamic environments.
Health and social care organisations should have in place a holistic and integrated system covering management, reporting, analysis and learning from all adverse incidents involving patients, clients, staff and others. The challenge is to change cultures and move towards a just, honest and open approach to incident reporting and analysis so that staff are involved and secure in sharing their experiences.
It is essential for health and social care organisations to establish the underlying causes of adverse incidents, errors and near misses. Unless the causes of an adverse patient/client experience are understood, lessons will not be learned and required changes cannot not be made to reduce the risk of future recurrence.
This programme sets out the key requirements for health and social care organisations to manage, report, analyse and learn from all adverse patient/client safety incidents.
This root cause analysis programme will
provide participants with the skills and expertise to
effectively apply the principles and learning from error
management techniques. A workshop approach is used to
allow the participants to share information and
experience. The programme syllabus includes:
- How to improve communication and interpersonal relationships within clinical teams
- How to support staff through the investigation process following an adverse patient safety incident
- How to address communication and public relations issues
- How to develop a robust risk assessment framework for patient safety incidents
- How to undertake a root cause analysis using a human factors approach
- How to formulate resulting action plans
- How to identify the lessons learnt and select appropriate methods for dissemination
- How to address cultural change issues