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Found 6 results
  1. Community Post
    Root case analysis has its detractors but can still bring value to understanding deep-seated problems that affect the safety of care. Does anyone have a checklist of elements of an effective TRAINING strategy to bring staff on board with the process? Not how to do an RCA, but to bring a team to the skill competencies they need to do RCA? I'd appreciate hearing your experiences. Please tell your tales!
  2. Content Article
    This perspective from the US discusses problems with the use of root cause analysis (RCA) in healthcare. The authors summarise research examining the process and share recommendations to enhance the use of RCAs from the National Patient Safety Foundation document RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
  3. Content Article
    Root cause analysis (RCA) is a recognised yet problematic process for examining failures deeply. The goal of RCAs are to identify systemic problems rather than blame individuals. Effective RCAs devise strategies to improve processes that mitigate conditions that contribute to failure. The RCA2 report is the result of a multidisciplinary consensus effort lead by the US-based National Patient Safety Foundation. The document outlines techniques to enhance the RCA process and enable organisations using the highlighted approaches to improve RCA efforts to more reliably impact improvement.
  4. Content Article
    The act of open disclosure of an adverse event alone may not be enough for patients or their families. Patients and patient advocates are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post‐event analysis allows risk management professionals to further improve their organisation's systems analysis process while empowering patients to be part of the solution. First published by the US-based Journal of Health Care Risk Management, this article examines the legal and psychological considerations surrounding the involvement of patients in system failure analysis and provides tools for selecting patients who are able to benefit from this process and for adequately preparing patients and caregivers for what lies ahead.
  5. Content Article
    A presentation by Shelia Yates on root cause analysis and Just Culture. Shelia is trained and educated in the performance of behaviour health services through interpersonal communications and analysis.
  6. Content Article
    This case study, published in Safety Science, looks at aviation to illustrate the conflict, and double-binds, created as those in high-consequence industries negotiate the fluid lines of accountability relationship boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova Scotia, in 1998. The paper offers dialogue to aid in understanding the influence accountability relationships have on safety, and how employee behavioural expectations shift in accordance. McCall and Prunchnicki propose that this examination will help redefine accountability boundaries that support a just culture within dynamic high-consequence industries.
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