GP.19.Root Cause Analysis: teaching aids (NPSA)
Web-editor's note (June 2007): The Good Practice descriptions from England and Wales (GP 18-21) are some examples of what can be found on the website of the National Patient Safety Agency (NPSA), London.
Root Cause Analysis Teaching (England & Wales)
Learning from experience is critical to NHS organisations and their staff in delivering a safe and effective service to patients and clients. The National Patient Safety Agency (NPSA) is committed to finding ways to help healthcare organisations understand the underlying causes of patient safety incidents and to formulate plans for improving safety.
Root Cause Analysis (RCA), is a retrospective review of a patient safety incident undertaken in order to identify what, how, and why it happened. The analysis is then used to identify areas for change, recommendations and sustainable solutions, to help minimise the re-occurrence of the incident type in the future. This approach is equally applicable to complaints and claims. The website provides pathways to learning the technique.
