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Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia

Correspondence to:
Professor J Braithwaite
Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; j.braithwaite{at}unsw.edu.au Background: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited.

Objective: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP).

Hypothesis: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety.

Design, setting and participants: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia.

Outcome measures: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired.

Results: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training.

Conclusions: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Abbreviations: NSW, New South Wales; RCA, root cause analysis; SIP, Safety Improvement Program

Relevant Article

From root causes to safer systems: international comparisons of nationally sponsored healthcare staff training programmes

L M Wallace
Qual. Saf. Health Care 2006 15: 388-389. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

				J. Braithwaite, M. Westbrook, and J. Travaglia Attitudes toward the large-scale implementation of an incident reporting system Int. J. Qual. Health Care, June 1, 2008; 20(3): 184 - 191. [Abstract] [Full Text] [PDF]

				A. W. Wu, A. K. M. Lipshutz, and P. J. Pronovost Effectiveness and Efficiency of Root Cause Analysis in Medicine JAMA, February 13, 2008; 299(6): 685 - 687. [Full Text] [PDF]

				L M Wallace From root causes to safer systems: international comparisons of nationally sponsored healthcare staff training programmes Qual. Saf. Health Care, December 1, 2006; 15(6): 388 - 389. [Full Text] [PDF]