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.