In a safe clinical environment, systems are
in place to prevent errors and to try to ensure
that patients are not harmed when errors
When error occurs, the customary focus
on blaming the individual care-giver overlooks
the conditions in which the error occurred.
This misses the opportunity for the organization
to learn how to make its environment safer.
Human error cannot be eliminated from
the clinical setting. Systems can be designed
to help individuals avoid error and minimise
the harmful effect of errors.
Root cause analysis is the systematic analysis
of all the factors which predisposed to,
or had the potential to prevent, an error.
It can be applied to incidents in which there
was avoidable patient harm, or in ‘near misses’
in which a situation or event put patients
at risk of harm. Organizations can use root
cause analysis both to explain how the
incident occurred and to design mechanisms
to prevent it from happening again.
There are many tools available for use in
root cause analysis. One tool is the ‘fishbone
technique’. Nine groups of contributory
factors are identified in this example. These
may be broken down into subgroups. For
example, patient factors may be subdivided
into clinical condition, social factors, physical
factors, mental and psychological factors and
interpersonal relationships. Each group of
factors can then be considered individually,
to assess its relevance to the specific incident
being studied. This method provides a prompt
for considering each of a wide range of
factors. It also allows contributing factors that
are identified to be displayed in a simple
To conduct root cause analysis certain steps
need to be taken:
1. Define which events require investigation;
for example those which were, or could
have been, fatal and might be repeated,
but which are felt to be preventable.
2. Select a multidisciplinary team, including
an expert in the specialty and a person
experienced in incident investigation.
3. Gather information by interviewing all
of the people involved (using free recall
and semi-structured interviews), reading
all available documentation, examining
equipment and inspecting the site at which
the event occurred. This may include
reconstruction of the event.
4. Collate information from all sources into
one user-friendly form, such as a timeline.
5. Ask all those who were involved to
identify what aspects of service delivery
they think contributed to the event, for
example by identifying how the event
deviated from normal practice.
6. Use an investigation tool such as the
fishbone template to identify factors that
contributed to, or had the potential to
prevent, the event.
7. Develop targeted recommendations
that could be implemented to reduce
the potential for this event to recur.
Recommendations should be simple,
specific and measurable; it is easy
to say but hard to implement a
recommendation that “everyone
should try not to do that again”.
8. Publish a report to share the lessons that
have been learnt within the organization
and more widely in health care.