Systematic Incident Investigation course for GPs
This session describes the use of Root Cause Analysis tools to systematically investigate patient safety incidents in general practice. Examples to improve your understanding of how to apply these tools appropriately are provided.
Learning Objectives
By the end of this session you will be able to:
- Describe when and how to apply different RCA methods and techniques
- Identify service delivery problems, care delivery problems and contributory factors that lead to patient safety incidents
RCA is important because the methodologies it provides enable those staff carrying out the incident investigation to think beyond human error. That is to say, to focus not only on what went wrong and how it happened, but also to identify why an incident occurred. So, in terms of Reason’s Swiss Cheese Model, RCA promotes the identification of latent conditions, as well as active errors.
Before commencing this session you should complete the sessions:
- Session - Introduction to Patient Safety
- Session - Root Cause Analysis in Primary Care
r Jane Carthey is a Patient Safety and Human Factors Specialist who has worked in the NHS for 13 years, both at a local Trust level and for a national agency. Dr Carthey has applied human factors methodologies to understand the causes of incidents in healthcare in acute and primary care settings. Her expertise includes incident reporting, organisational and team safety culture, observational data collection, incident investigation, prospective risk assessment and improving communication between patients and healthcare staff when things go wrong.
Christine has worked as a GP in Nottingham since 1988.
Through her undergraduate work at the University of Nottingham as Community Sub Dean and postgraduate work as part of Health Education East Midlands, she has been involved in the delivery of education to both medical and multi-professional audiences with a particular emphasis on Quality Improvement and Patient Safety.
She represents Vale of Trent on the RCGP Council.
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