Abstract
While the requirement to analyse and learn from adverse events of all kinds is now well established within the National Health Service (NHS), the practice of systematic investigation and analysis is acknowledged by many working in the service to be, at best, variable. In my experience of teaching the principles and practice of root cause analysis, many NHS staff are expected to participate in or even lead complex investigations after only a short training programme, usually with minimal support and high expectations of the outcome. This book is here to help. It is not a ‘teach yourself RCA’ guide, nor should it be, but it is a comprehensive resource for practitioners.
Previous editions of this handbook have sought to provide investigators with a compendium of information about the key stages of what is a systematic problem-solving methodology, supplemented with lessons from the author's experience. Inevitably, the third edition has further examples and practical tips which will be of tremendous value for those who have some knowledge of the topic and its context.
The reader using the book as a reference to find specific advice and examples is not helped by a rather pedestrian layout; there is no index beyond the table of contents, there are few graphics, aside from in the appendices, and bullet point lists are over-used, but these are very minor gripes in what is clearly a work emanating from knowledge and first-hand experience, as well as obvious enthusiasm.
The case studies are particularly helpful and represent a range of healthcare settings. Some suggestions for the investigation facilitator on using colour coding and cutting out/folding card etc may indicate that the influence of Blue Peter is still alive and well. Again, from personal experience, these sorts of practical tips add value in two ways: firstly they are effective and secondly they can make group activities more enjoyable and less stressful for participants. Managing people involved at different stages of investigation is as important a skill as understanding the techniques of gathering and analysing information: the author makes this abundantly clear.
The importance of validating evidence is also emphasized and, again, there is some practical advice for ensuring the trail of evidence is transparent. This issue is absolutely pivotal if the root cause analysis process is to facilitate learning and change. If there are concerns that investigations may not always be commissioned with complete clarity or, more worryingly, objectivity, a robust approach to validating evidence is key. This edition is also helpful on the development of recommendations, linking them to the original harm. There is a clear example of a measurable action plan: this section of the book would be valuable reading for all staff involved with developing quality and safety programmes or indeed anyone who has ever written or been ‘named’ in an action plan!
Six Steps to Root Cause Analysis remains a standard and comprehensive reference for investigators and others with knowledge of investigation and analysis who seek to learn from experience in healthcare. It continues to be relevant and current and is characterized throughout by reference to real examples and practical experience.