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Masterclass: Using Root Cause Analysis to Learn from Deaths

Monday 11 December 2017
De Vere West One Conference Centre, London

Masterclass: Using Root Cause Analysis to Learn from Deaths
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The CQC review ‘Learning, candour and accountability; a review of the way NHS trusts review and investigate the deaths of patients in England’ (December 2016) concluded that Trusts should be doing more in terms of their analysis and learning from patient deaths and how they involved families in the process. 
The follow up report by the National Quality Board stipulated that an investigation is:
“The act or process of investigating; a systematic analysis of what happened, how it happened and why. This draws on evidence, including physical evidence, witness accounts, policies, procedures, guidance, good practice and observation - in order to identify the problems in care or service delivery that preceded an incident to understand how and why it occurred. The process aims to identify what may need to change in service provision in order to reduce the risk of future occurrence of similar events.”

It recommended: “Providers should review and, if necessary, enhance skills and training to support this agenda. Providers need to ensure that staff reporting deaths have appropriate skills through specialist training and protected time under their contracted hours to review and investigate deaths to a high standard.”

This interactive and practical course will provide a structured approach (Root Cause Analysis) to investigating and learning from deaths.  Delegates will be guided through gathering the evidence, conducting a detailed analysis of the issues and evidence and production of the final report.

The methodology taught will be one that can be incorporated into the health professional’s working day.

All techniques will be tested through role-play.

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