Exploring a root cause analysis team's experience with involving patients and next of kin after a sentinel event

There is a growing recognition among healthcare providers and policymakers of the importance of involving patients and their next of kin in root cause analysis (RCA) to improve patient safety and healthcare quality. However, such involvement is intricate and challenging. This study explored how the involvement of patients and next of kin influenced the RCA team's understanding of a fatal sentinel event in maternity care.

The study was a qualitative exploratory single-case study combining document analysis with interviews with six RCA team members. The selected case came from a Norwegian hospital responding to a sentinel event involving the unexpected death of a child during childbirth. The study addressed the following research questions: What were the team's experiences of involving patients and next of kin in the RCA process? Data collection included twelve interviews with six RCA team members, which were analysed using reflexive thematic analysis.

Four main themes were identified. These concerned: (1) uncertainty regarding whether bereaved parents should be involved in the RCA process; (2) challenges associated with conducting interviews with the parents; (3) incorporation of patient and next-of-kin perspectives into the RCA report; and (4) the RCA team's learning process following involvement of the parents.

The findings suggest that involving patients and next of kin in RCA processes may contribute perspectives that strengthen organisational learning and understanding of sentinel events. Future research should explore how RCA frameworks can be systematically adapted to accommodate the involvement of bereaved relatives across different healthcare contexts.