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While traditional methods such as Failure Mode and Effects Analysis (FMEA) are well-established, they often reach their limits in clinical practice. This is due in particular to the subjectivity of fault identification. I would like to propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. HAZOP offers a structured, systematic approach to risk identification and assessment, particularly suited to analysing process risks and human factors. Unlike FMEA, HAZOP uses guide words (e.g. NO, MORE, LATE, LESS, OTHER THAN) to explicitly identify and analyse potential deviations from tasks and procedures.  A systematic approach to identifying and assessing clinical risks Despite the implementation of risk management systems, practice often falls short of expectations. This is due, among other factors, to the complexity of clinical processes, the dynamics of the work environment, and interprofessional interfaces, which make a holistic risk assessment difficult. Although traditional methods are widely used, they reach their limits in clinical practice: Subjectivity: When using traditional methods such as FMEA, which rely on the team’s spontaneous fault detection and experience, critical risks are easily overlooked as they are not recognised as ‘failure modes’. Monocausality: Traditional failure-mode-based approaches lead to a monocausal derivation of causes and effects. Human factors as ‘operator error’: Human errors are easily classified as ‘user problems’ without questioning the systemic causes (e.g. time pressure, unclear responsibilities, inadequate communication). Against this background, I propose the Hazard and Operability Study (HAZOP) as a complementary risk analysis method. The HAZOP method was originally developed in the aviation industry and has established itself there as the gold standard for analysing risks in highly complex, safety-critical environments. HAZOP enables the approach required by ISO 31000 as a structured, step-by-step approach: Risk identification Risk analysis Risk evaluation Risk identification using guide words The method uses guide words as a heuristic to systematically identify potential process deviations as a starting point for the risk analysis. These guide words are adapted to clinical reality and enable a comprehensive risk analysis: Guide Word: Possible deviation. No: Failure to perform a task. More: Excessive performance of a task. Less: Inconsistent performance of a task. Late: Delayed performance of a task. Other than: Incorrect execution of a task. Using guide words as a starting point for risk identification also helps to involve those with little experience in risk management in the process. A list of guide words can and should be adapted to the specific requirements of the specialist department. Practical application: Example 'documentation of vital signs' Task: Recording and documenting vital signs in the intensive care unit. Guide word: Possible deviation No: Blood pressure is forgotten. Late: Documentation is delayed, delaying further diagnosis. Less: Not all vital signs are measured. Other than: A mix-up of patients in the documentation. Risk analysis The identified risks can be assessed using a two-dimensional risk matrix, like in other risk tools: Probability of occurrence (scale: ‘almost impossible’ to ‘almost certain’). Impact (scale: ‘no health consequences’ to ‘life-threatening consequences’). This commonly used and well-known assessment method enables measures to be prioritised and helps hospitals to proceed in a resource-efficient way. Risk evaluation and identification of measures Preventive and corrective measures are developed during interprofessional workshops, in which representatives from all relevant professional groups (doctors, nursing staff, administration, IT) work together to evaluate risks and propose solutions. Typical measures include: Process optimisations (e.g. standardisation of documentation procedures). Training to raise awareness of human factors. Technical adjustments (e.g. introduction of digital checklists). Clarification of responsibilities (e.g. through clear SOPs). Discussion The HAZOP method offers several key advantages that are particularly relevant to clinical patient safety: The use of guide words enables risks that are often overlooked to be systematically identified. This reduces subjectivity in error detection and enables more objective prioritisation of measures. The method allows for the analysis of human and organisational factors. This enables a holistic view of incident causes and supports hospitals in developing systemic solutions. HAZOP can be seamlessly integrated into the SEIPS 2.0 approach, which enables a coherent risk assessment that accounts for all relevant factors. The approach promotes collaboration among professionals from different disciplines. This strengthens the learning culture and helps to close governance gaps. Thanks to the structured approach and the use of guide words, risk analysis can be carried out more quickly and efficiently. Conclusion The HAZOP method, with its guide words, is a proven, systematic and evidence-based tool for improving clinical patient safety. It enables a comprehensive risk analysis that takes into account technical, procedural and human factors. Do you use the HAZOP method? We would love to hear from you if you're using HAZOP in a clinical setting so we can share real-life examples of its use. Email us at [email protected] or comment below (you need to be signed into the hub; sign up here, it is free and easy to do).

RCA continues to be used around the world by healthcare teams to better understand and learn from their patient safety incidents. While it is no longer an approved learning response under the NHS Patient Safety Incident Response Framework (PSIRF), many care and non NHS organisations continue to use RCA as a structured and effective approach for understanding incidents and improving safety. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. This course supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. Register hub members receive a 20% discount. Email [email protected] for discount code.

This two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email [email protected] for discount code.

This two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. The new National Patient Safety Incident Response Framework (PSIRF) published in 2020 highlights important changes to the way safety incidents will be investigated, which is reflected in this course. Key new content includes: Promotion of RCA as a tool for learning & improvement. Emphasis on increased use of listening & interview (staff and patients) to gain a better understanding of what has happened. The importance of Safety II and focusing on system strengths, plus linking RCAs to QI & clinical audit. More emphasis on human factors. Brief information on approaches that may be more appropriate to RCA (e.g. significant event analysis, after-action reviews). Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. Register hub members receive a 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. We pay particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. We advocate Root Cause Analysis as a teambased approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. Register

This virtual workshop will provide paramedics with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register

This virtual workshop will provide paramedics with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register

This virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register

This virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register

This virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register

This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email: [email protected]. hub members receive 20% discount. Email [email protected] for discount code.

This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-1-day-masterclass or email [email protected]. hub members receive a 20% discount. Email [email protected] for discount code.