Root Cause Analysis (RCA) Training in Healthcare

A key requirement for safety focused health care organisations is to manage, report,
analyse and learn from all patient safety incidents.

It is no longer sufficient for health care providers to learn and improve only from errors. A proactive risk management approach, together with a reactive process of patient safety incident management will aid the identification of things that COULD go wrong.

Root cause analysis, provides the tools and techniques to identify and understand the underlying causes of incidents, to promote learning from the incident and to determine the necessary corrective actions to prevent or reduce the likelihood of re-occurrence.

Healthcare organisations should analyse incidents rapidly after they occur, so that immediate risks are removed for those involved in the incident. Furthermore, where appropriate, incidents should be analysed to identify root causes, and the likelihood of repetition, in order to prevent the reoccurrence of incidents in the future. Information arising from the analysis of incidents must also enable the identification of actions required to prevent similar occurrences.

Global Air Training RCA courses are interactive, drawing on the participant’s knowledge, skills and experience, using up-to-date case studies and simulation. In addition, the Train-the-Trainer course includes instructional techniques, opportunities for participants to develop teaching materials and practice in the delivery of training sessions.

• Reduce the risk of harm to patients through a teamwork approach to patient safety.
• Developing patient-focused rather than task focused systems.
• Effective  coordination throughout the patient care pathway.
• Improving situational awareness.
• Improving workload management.
• Developing team skills and behaviours which reduce the occurrence of clinical errors.

The training introduces proven methodologies for improving team working, removing organisational barriers and flattening hierarchies. These techniques promote learning from experience, develop cognitive and interpersonal skills and highlight the benefits of good teamwork in the prevention of adverse patient safety incidents.

The training sessions reference and examine human factor related adverse events and near misses. Sessions include the use of training video footage, incident reports, case studies, simulation exercises, group discussions and incident reviews. The programme is designed to address the nature of the organisation's day-to-day operations as well as the associated protocols and procedures, including areas that produce particular difficulties, adverse conditions and any unusual hazards.

The outcomes of the programme will ensure that the participants have a greater awareness and understanding of how human factors and performance limitations can lead to unsafe practice. The participants will be able to identify the clues that reveal an incipient error chain and select and apply appropriate intervention strategies.

For maximum effectiveness, complete organisational involvement is required in a TRM training programme. This involvement should become an ongoing part of the programme. A key challenge for TRM programme leaders is to communicate that need to the rest of the organisation and to establish a strong commitment from top management down.

Case Study - Stoke Mandeville Hospital Clostridium Difficile Outbreak

Global Air Training was involved in the support programme designed to assist the Buckinghamshire Hospital NHS Trust in meeting the challenges created by a series of outbreaks of clostridium difficile infection. The Trust first noted an increase in the cases of clostridium difficile in 2003 with two subsequent peaks in the numbers reported in March 2004 and February 2005. The Stoke Mandeville Hospital was indentified at the time as having the highest incidence of the infection across the Trust. Further analysis has shown this particular strain of the bacterium to be unusual and the Trust had made every effort to seek information and guidance, from both national and international organisations with experience in dealing with this type of strain.

This is not just an issue for Buckinghamshire Hospital NHS Trust as nationally there has been a rise in the number of reported incidents of clostridium difficile in recent years with rising numbers of cases year on year. An increase of 97% in the number of incidents of c. difficile was reported between 2001 and 2004. This rise nay be attributed to improved reporting of cases, particularly to the Health Protection Agency, and better awareness and diagnosis of the infection.

Global Air Training led a multidisciplinary group of hospital staff through the root cause analysis process with the specific aim of enabling selected participants to understand the in-depth analysis process necessary to identify actions that would assist the Trust in preventing and controlling future outbreaks of the infection.

 

Root Cause Analysis Programmes

The courses use a structured and disciplined, human factors based approach to incident investigation and analysis.
The syllabus includes:

• Review of National and International
  Research & Guidance.
• Lessons from Other Industries.
• Human Factors Approach.
• Incident Investigation Techniques.
• Incident Decision Tree.
•  Deliberate Harm Test.
• Root Cause & Systems Analysis.
• Writing the Investigation Report.
• Action Planning.
• Embedding Lessons Learned.
• Cultural Issues

Downloadable Course Programme

Click below to download the course proramme in pdf format.

• Root Cause Analysis