Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited.

To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP).

Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety.

Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia.

Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired.

No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training.

RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.