Root Cause Analysis

Ensuring patients and service users are treated safely is the top priority for healthcare staff. When incidents do happen, it is important that lessons are learned and shared to prevent the same incidents occurring again or elsewhere.

Root Cause Analysis (RCA) investigations are an easy and well-recognised way of doing this, offering a framework for reviewing patient safety incidents (and claims and complaints). Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions to minimise the recurrence of the incident type in the future.

When should and RCA be undertaken?
Undertaking a RCA when a patient has a confirmed healthcare associated infection (HCAI), such as meticillin-resistant Staphylococcus aureus (MRSA), or Clostridium difficile infection (CDI), is an essential activity. A RCA should ensure registered providers reduce the risk of infection and strive to provide safer care for future patients.

Working through the RCA process allows organisations to understand areas requiring improvement in the patient care pathway, and more importantly, identifies and targets actions to effectively minimise the chance of recurrence. A clearly defined process embedded throughout the registered provider is the key to a successful RCA.

What is the process for undertaking a RCA?
Once an RCA process has been completed it is important for organisations to develop a plan of action which is able to track any improvements that are needed to prevent or minimise the risks of the incident occurring again. A key part of this plan is how organisations assure themselves or “test” how it has well it has implemented. Examples of this assurance could be compliant clinical practice audits or achieving the required hand hygiene or isolation standards.

The root causes and any associated learning should be fed into an organisations governance structure to support other areas to understand the event and ensure they are able to undertake similar risk reduction in their area.

As HCAIs do not adhere to organisational boundaries the need to involve other health partners during the RCA process and afterward offers real benefits in taking every opportunity during the patient pathway to minimise the risk of infection.

RCA Training Package
The following training package has been developed to support the work on Root Cause Analysis undertaken by the National Patient Safety Agency (NPSA)

Its aim is to support registered provider staff in reducing healthcare associated infection (HCAI) through improved knowledge, understanding and application of RCA for HCAI.

This training package has been designed to be delivered as a three hour training session. It can be delivered as a stand-alone package or adapted to meet local needs.

For Participants
Introduction and Background (PDF, 17.3 KB)

Competencies (PDF, 23.4 KB)

Timetable for day (PDF, 24.6 KB)

Learning Outcomes for Sessions (PDF, 24.1 KB)

RCA Slides for sessions 1 to 7 (PPT, 1.5 MB)

Competency self-assessment form (PDF, 15.8 KB)

RCA Process (XLS, 175.1 KB)

MRSA data gathering tool (XLS, 237.6 KB)

Clostridium difficile data gathering tool (XLS, 223.2 KB)

Evaluation form (PDF, 17.3 KB)

Case Studies (11 documents)
Case Study 1 – Summary Case History for Patient A (PDF, 19.3 KB)

Case Study 2 – Acute Antibiotic Policy (PDF, 1.9 MB)

Case Study 3 – Acute MRSA Policy (PDF, 87.8 KB)

Case Study 4 – Acute Multidisciplinary Assessment (PDF, 1.1 MB)

Case Study 5 – Acute Records (PDF, 3.2 MB)

Case Study 6 – Catheter Care Policy (PDF, 1.9 MB)

Case Study 7 – District Nurse Records (PDF, 58.2 KB)

Case Study 8 – Drug Chart (PDF, 2.1 MB)

Case Study 9 – GP Records (PDF, 788.2 KB)

Case Study 10 – Time Line for Patient A (PDF, 19.3 KB)

Case Study 11 – RCA for Patient A (XLS, 225.8 KB)

Case Study 12 – RCA action plan for patient A (PDF, 25.0 KB)

RCA Training – NPSA Five Whys handout (PDF, 202.2 KB)

For Trainers
And in addition, the trainers or course facilitators will require:

RCA Training – Trainers timetable for day and pre-course preparation (PDF, 27.1 KB)

RCA Training – Session (lesson) plan and learning outcomes PDF, 56.1 KB)

RCA Slides for sessions 1 to 7 (PPT, 1.4 MB)

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