Root cause analysis is an obsolete method for incident investigation as it doesn't permit the identification of interactions between system factor, 👇 case study shows use of #SEiPS & #Accimaps to achieve that @msonetwork @MedSafeTeamNI @IMSN_ie
Root cause analysis is an obsolete method for incident investigation as it doesn't permit the identification of interactions between system factor, 👇 case study shows use of #SEiPS & #Accimaps to achieve that @msonetwork @MedSafeTeamNI @IMSN_ie
@amecarrington @msonetwork @MedSafeTeamNI @IMSN_ie Root cause analysis still has a role in some investigations, possibly not in healthcare, but that is more likely due to poor introduction and implementation. You can, in fact, explore reactions but focus on the root cause being singular and not plural, reduces its effectiveness
@ChrisElston1912 @msonetwork @MedSafeTeamNI @IMSN_ie So #HTA ( which was mentioned) #CWA, #FRAM & #STAMP enable more depth and also #bowtie to understand system resilience but use of these is rare in healthcare and really requiring more support from #HFE practitioners @pbnes @KenCatchpole @Laurapickup1 @MarkSujan @StevenShorrock
@amecarrington @ChrisElston1912 @msonetwork @MedSafeTeamNI @IMSN_ie @pbnes @Laurapickup1 @MarkSujan @StevenShorrock If you move beyond “error” and root cause(s) - which entirely depend on your ‘stopping rule’ - and adopt non- linear and systems thinking it yields a huge number and variety of possibilities for improvement. If not, the same things will keep happening, and you won’t know why.
@amecarrington @msonetwork @MedSafeTeamNI @IMSN_ie @pbnes @KenCatchpole @Laurapickup1 @MarkSujan @StevenShorrock There is the £64 billion question. We need more HF practitioners but at what level in healthcaree, ICB or each Trust. I have about 20 years before I retire, I reckon that is one change I can make...maybe this one?