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1. pubmed.ncbi.nlm.nih.gov › 32339023Root cause analysis in the NHS: time for change? - PubMed

   pubmed.ncbi.nlm.nih.gov › 32339023

   Apr 2, 2020 · A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics.

   • Author: Shyam Kumar, Roger Kline, Tracy Boylin

   • Publish Year: 2020

2. www.magonlinelibrary.com › doi › fullRoot cause analysis in the NHS: time for change? | British ...

   www.magonlinelibrary.com › doi › full

   Apr 8, 2020 · A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics.

   • Author: Shyam Kumar, Roger Kline, Tracy Boylin

   • Publish Year: 2020

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4. www.nhselect.nhs.uk › Root-cause-analysis-guideRoot cause analysis guide - NHS Elect

   www.nhselect.nhs.uk › Root-cause-analysis-guide

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   Discover the power of the five whys with our guide to root cause analysis. This practical resource helps you uncover underlying issues, streamline problem-solving, and implement effective solutions. Useful for any improvement project, it helps enhance understanding and drive lasting improvements.

5. www.england.nhs.uk › wp-content › uploadsGuide to responding proportionately to patient safety incidents

   www.england.nhs.uk › wp-content › uploads

   The NHS is well versed in root cause analysis (RCA). However, although RCA was designed to be system-based and go beyond the more usual identification of fault and blame (see the London Protocol1), this approach to learning from patient safety incidents has been under-realised.

6. www.england.nhs.uk › wp-content › uploadsPatient Safety Incident Response Framework 2020 - NHS England

   www.england.nhs.uk › wp-content › uploads

   This framework requires providers of NHS-funded care to develop a patient safety incident response plan (PSIRP), in line with the national PSIRP template. The aim of this is to support a strategic, risk management approach to balancing the activity and range of incident responses with those of safety improvement.

   • File Size: 1MB

   • Page Count: 100

7. www.sciencegate.app › document › 10Root cause analysis in the NHS: time for change? - ScienceGate

   www.sciencegate.app › document › 10

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   <jats:p> Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering appro ...

8. People also ask

   What is a human factors approach to root cause analysis?

   • A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks.

   Root cause analysis in the NHS: time for change? - PubMed

   pubmed.ncbi.nlm.nih.gov/32339023/

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   What is a root cause analysis?

   • Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation.

   Root cause analysis in the NHS: time for change? - PubMed

   pubmed.ncbi.nlm.nih.gov/32339023/

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   Is root cause analysis system-based?

   • Is root cause analysis ‘system-based’? The NHS is well versed in root cause analysis (RCA). However, although RCA was designed to be system-based and go beyond the more usual identification of fault and blame (see the London Protocol1), this approach to learning from patient safety incidents has been under-realised.

   Guide to responding proportionately to patient safety incidents

   www.england.nhs.uk/wp-content/uploads/2022/08/B1465-3.-Guide-to-responding-proportionately-to-patient-safety-incidents-v1-FINAL.pdf

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   Is root cause analysis an impediment to patient safety?

   • Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety.

   Root cause analysis in the NHS: time for change? - PubMed

   pubmed.ncbi.nlm.nih.gov/32339023/

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   Can root cause analysis be eliminated?

   • If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided. Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach.

   Root cause analysis in the NHS: time for change?

   www.magonlinelibrary.com/doi/full/10.12968/hmed.2019.0352

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   Who should perform a root cause analysis?

   • The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised.

   Root cause analysis in the NHS: time for change? - PubMed

   pubmed.ncbi.nlm.nih.gov/32339023/

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9. bmjopenquality.bmj.com › content › 12Thematic reviews of patient safety incidents as a tool for ...

   bmjopenquality.bmj.com › content › 12

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   A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents.