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Donna Forsyth NHS England discusses the core principles of effective Root Cause Analysis in Health & Social Care

Donna Forsyth, Head of Patient Safety Investigation, NHS England discussed the core principles of effective Root Cause Analysis in Health & Social Care at today’s conference. In her presentation Donna discussed in-depth:

  • core principles of an effective Root Cause Analysis
  • triggers for RCA investigation
  • putting the theory into practice
  • looking at aggregated results of RCA’s for patterns

Donna Forsyth’s full presentation is available for download at the end of this page

In her presentation Donna looked at:

Triggers for investigation are Acts and / or omissions occurring as part of NHS-funded healthcare that result in:

  • Never Events: http://www.england.nhs.uk/ourwork/patientsafety/never-events/
  • Unexpected or avoidable death caused or contributed to by weaknesses in care/service delivery 
  • Unexpected or avoidable injury as above that has resulted in serious harm 
  • Unexpected or avoidable injury that requires further treatment to prevent death or serious harm 
  • Physical or psychological ill-treatment or neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery (e.g  SCR, DHR) 
  • An incident that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services 
  • Major loss of confidence in the service (e.g. prolonged adverse media coverage or public concern about the quality of healthcare or an organisation)

The NHS Investigation Process - Getting Started, Gathering Information, Mapping the incident, Identifying Care & Service Delivery Problems, Analysing Problems & Identifying CFs and RCs, Generating Solutions & Recommendations, Writing the Report

Core Principles

  1. Those leading systems investigation must be properly trained and experienced in investigation 
  2. Serious incidents should not be investigated by one person 
  3. The national good practice framework and investigation report template must be used for every serious patient safety investigation 
  4. Patients and/or their relatives must be properly involved in every serious incident investigation  
  5. No NHS Staff member should be blamed for making an honest mistake 
  6. Conduct fewer, better investigations

Always use the National patient safety Investigation report template to:-  

  • Facilitate consistency of quality and layout 
  • Facilitate trend analysis, audit and shared learning 
  • Assist in the demonstration of a robust methodology 
  • Speed up the Report Writing phase of the investigation

“Are you conducting more and more investigations on the same subject and uncovering similar outcomes?  What is that telling you?  Time must be allocated to selecting and implementing effective solutions and monitoring practice.”

Purpose of the Investigation Report if to provide: 

  • a formal and transparent record of the investigation process 
  • a means of sharing learning  

Audiences will use the content, style & tone to judge: 

  • the quality of the investigation process, findings, conclusions and recommendations 
  • the competence of the investigation team

“Simply telling people to be more careful doesn’t work”

Donna Forsyth’s Biography:

Donna began her career as a Physiotherapist and held Superintendent and clinical supervisory positions as a musculoskeletal specialist. In 1998 she qualified as a Chartered Safety Practitioner, introducing and embedding whole systems risk management in an Acute Trust.

Whilst at NPSA from 2003 Donna’s roles included Head of NRLS Reporting and Head of Investigation and Training. She has worked collaboratively with the World Health Organisation since 2007 as an expert adviser on event analysis, and has co-authored internationally recognised guidance and chapters on good practice in healthcare investigation. In 2010 Donna completed air accident investigation training at Cranfield University. More recently she has initiated and led an 18 month pilot of the world’s first ‘Investigation Branch’ for health.

Future related events:

Root Cause Analysis: 2 Day Intensive Training Course
Thursday 9 July — Friday 10 July 2015, London

Tuesday 25 - Wednesday 26 August 2015, London

Tuesday 15 - Wednesday 16 September 2015, London

Tuesday 13 - Wednesday 14 October 2015, London

Wednesday 4 - Thursday 5 November 2015, London

Wednesday 9 - Thursday 10 December 2015, London

Improving Patient Safety in Independent Healthcare
Wednesday 1 July 2015 
Hallam Conference Centre, London

Managing when a Serious Clinical Incident Occurs
Wednesday 8 July 2015 
Hallam Conference Centre, London

Masterclass: Root Cause Analysis for Beginners
Thursday 10 September 2015 
Hallam Conference Centre, London

Reducing & Monitoring Avoidable Hospital Deaths attributable to problems in care
Thursday 8 October 2015 
Hallam Conference Centre, London

Leading your Organisation to Zero-Harm
Thursday 22 October 2015, Manchester

Thursday 10 December 2015, London


Download: Donna Forsyth"s full presentation

24 June 2015

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