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 important for health and social care organisations and their staff to establish the underlying causes of adverse incidents, errors and near misses. Unless the causes of an adverse patient/client experience are properly understood lessons will not be learned and required changes will not be made to reduce the risk of harm to future patients.
|
