Abstract
Objectives: Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events. Design: Qualitative and quantitative retrospective analysis of RCA reports. Setting: A large acute healthcare Trust in London. Participants: None. Interventions: None. Main outcome measure: Quality of RCA reports, robustness of actions proposed. Results: RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events. Conclusion: Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.
| Original language | Portuguese |
|---|---|
| Pages (from-to) | 196-203 |
| Number of pages | 8 |
| Journal | International journal for quality in health care : journal of the International Society for Quality in Health Care |
| Volume | 32 |
| Issue number | 3 |
| DOIs | |
| Publication status | Published - 20 May 2020 |
Keywords
- Incident reporting
- Never Events
- Organizational learning
- Resilient healthcare
- Root cause analysis
- Safety-II