Using Safety-II and resilient healthcare principles to learn from Never Events.
- Resource Type
- journal article
- Authors
- Anderson, Janet E; Watt, Alison J
- Source
- International Journal for Quality in Health Care. Apr2020, Vol. 32 Issue 3, p196-203. 8p. 3 Charts, 2 Graphs.
- Subject
- *ROOT cause analysis
*INVESTIGATION reports
- Language
- ISSN
- 1353-4505
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. [ABSTRACT FROM AUTHOR]