Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes

Abstract

BackgroundRoot cause analysis (RCA) originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning. Despite the limitations of the RCA evidence base, healthcare authorities and decision makers in NHS Scotland – similar to those internationally - have invested heavily in developing training programmes to build local capacity and capability, and this is a cornerstone of many organizational policies for investigating safety-critical issues. However, to our knowledge there has been no systematic attempt to follow-up and evaluate post-training experiences of RCA-trained staff in Scotland. Given the significant investment in people, time and funding we aimed to capture and learn from the reported experiences, benefits and attitudes of RCA-trained staff and the perceived impact on healthcare systems and safety.MethodsWe adapted a questionnaire used in a published Australian research study to undertake a cross sectional online survey of health care professionals (e.g. nursing & midwifery, medical doctors and pharmacists) formally trained in RCA by a single territorial health board region in NHS Scotland.ResultsA total of 228/469 of invited staff completed the survey (48%). A majority of respondents had yet to participate in a post-training RCA investigation (n=127, 55.7%). Of RCA-experience staff, 71 had assumed a lead investigator role (70.3%) on one or more occasions. A clear majority indicated that their improvement recommendations were generally or partly implemented (82%). The top three barriers to RCA success were cited as: lack of time (54.6%), unwilling colleagues (34%) and inter-professional differences (31%). Differences in agreement levels between RCA-experienced and inexperienced respondents were noted on whether a follow-up session would be beneficial after conducting RCA (65.3% v 39.4%) and if peer feedback on RCA reports would be of educational value (83.2% v 37.0%). Comparisons with the previous research highlighted significant differences such as less reported difficulties within RCA teams (P<0.001) and a greater proportion of respondents taking on RCA leadership roles in this study (P<0.001).ConclusionThis study adds to our knowledge and understanding of the need to improve the effectiveness of RCA training and frontline practices in healthcare settings. The overall evidence points to a potential organisational learning need to provide RCA-trained staff with continuous development opportunities and performance feedback. Healthcare authorities may wish to look more critically at whom they train in RCA, and how this is delivered and supported educationally to maximize cost-benefits, organizational learning and safer patient care.

Fatores intervenientes na produção do cuidado em enfermagem

“…(15) The educational process is another essential service for the qualification of nursing staff, in the sense that this adds knowledge and increases the feeling of emotional security of the professional, enabling him/her to perform his/her practice in a competent, independent and collaborative way, which consequently impacts the quality of care. (16) The organizational environment can strongly influence the ability of nurses to build and maintain a therapeutic relationship with patients. This contact provides clinical supervision and follow-up of the interventions made by the technical team and establishes a more direct relational care with patients.…”

Implementation of an Interprofessional Team Review of Adverse Events in Obstetrics Using a Standardized Computer Tool: A Mixed Methods Study

“…This group can gain experience and will have opportunities to retain their skills in reviewing incidents, especially when a new tool such as SCOR is used. 22 It has been shown that the interprofessional team is instrumental in role modelling, learning from mistakes, and taking a non-punitive approach to adverse events; this in turn promotes improved engagement among the staff in the unit. 22,23 One of the limitations of our study was the small number of incidents reviewed by the team.…”

“…22 It has been shown that the interprofessional team is instrumental in role modelling, learning from mistakes, and taking a non-punitive approach to adverse events; this in turn promotes improved engagement among the staff in the unit. 22,23 One of the limitations of our study was the small number of incidents reviewed by the team. However, as a result of this short pilot project there is interest at our institution in adopting this program for use as the standard method for quality assurance review.…”

Critical Incident Analysis: Equip to Avoid Failure

“…Popular frameworks include the conceptual model (Ochberg et al 2007) and root cause analysis (RCA) (Bowie et al 2013). Uberoi et al (2007) suggested that RCA is a tool to identify prevention strategies, a process that is part of the drive to build a safety custom and move away from a blame culture.…”

“…RCA has been defined by Bowie et al (2013) as a structured approach to the investigation of patient safety incidents that is commonly applied in modern health systems worldwide, particularly in acute settings. The goal of RCA is to find out what happened, why it occurred and how to prevent it happening again.…”