Incident Investigation and Root Cause Analysis
Training Resources for Health Care Professionals

These resources are intended to address recognized barriers faced by health care professionals in conducting effective root cause analysis (RCA) of unexpected and undesired events. They present modern perspectives on accident causation, human error and performance, and design of tasks, processes, and systems. These resources incorporate fundamental safety management and systems performance principles and practices drawn from inside and outside of health care. Materials have been tested and refined over the course of three years with input from more than 500 health care professionals.*

Funding for developing the training materials was provided in 2007 through a grant titled “Rural Hospital Quality Improvement Project” from the Utah Department of Health’s Office of Primary Care & Rural Health.

The authors of these materials acknowledge the Veterans Health Administration’s National Center for Patient Safety’s Root Cause Analysis training course and the VA’s Midwest Patient Safety Center of Inquiry’s training course “Performance Experts in Safety” as critical to the development of this course.

We appreciate your comments, suggestions, or feedback on these materials

*See: Sweitzer S & Silver MP. Learning from unexpected events: A root cause analysis training program. J Healthcare Quality. 2005; 27(5): 11-19.

MODULES

0.1 Resource Overview

This module orients potential users to the content and structure of the Incident Investigation and Root Cause Analysis training resource. Lecture.
Intended for managers and facilitators of root cause analysis processes.

Root Cause Analysis Foundations

1.1 Learning from Unexpected Events

This module describes the role of RCA in the context of a comprehensive safety management function and the importance of learning from “near-miss” events. Barriers and risks to effective RCA efforts, and related training resources, are reviewed. The module includes lecture, examples, and exercises.

Suitable for all users; provides an orientation for patient safety professionals, leadership, governance, safety committee members, and staff.

1.2 Selecting Events for Investigation

This module describes methods for selecting events for investigation based primarily on their expected impact and likelihood of recurrence.

Primarily for patient safety professionals, but also suitable for leadership, safety committee members, and staff.

RCA Briefing

2.1 Introduction to Root Cause Analysis

This module outlines the purpose and goals of RCA, reviews barriers to effective investigations, and provides tools that can be used in analyses.

This module is intended specifically to orient teams charged with investigating and analyzing an event. It is also suitable others interested in RCA principles, including leadership, governance, safety committee members, and staff.

Special Topics in Event Investigation and Systems Design

3.1 Introduction to Human Factors

The module provides a high-level overview of human cognitive performance, the development of expertise, error, and implications for root cause analysis.

This module is suitable for anyone involved in RCA or process improvement efforts. It is also recommended for leadership, governance, safety committee members, and other staff.

3.3 Causal Tree Analysis

The module introduces an analysis technique for RCA teams. Use of this technique will promote a thorough and disciplined review of the event, facilitate group interactions, and improve communications about findings.

This module intended for teams directly involved in RCA efforts.