We have provided a number of Root Cause Analysis workshops this year. However, we have been aware of the international evidence cumulating about the shortcomings of root cause analysis as a patient safety approach.

So earlier this year, we developed a new Failure Mode and Effects Analysis (FMEA) workshop and tried out the workshop with a group of doctors, particularly specialist registrars. In the workshop, the doctors:

• identified high-risk clinical processes in their specialties
• considered how these processes could fail and result in an unsafe situation for patient care
• risk assessed the potential failures in these high-risk processes
• analysed the root causes of the possible failures
• planned action to discuss with their colleagues to make the clinical processes safer for patients.

The doctors who participated rated the workshop very well. Their comments included ‘need to get more people to go through this workshop’; ‘helps to try to change the ‘blame culture’ in incident reporting’; and ‘needs to be reported for each clinical department’.

This month, at the request of one of our customer organizations, we customized our FMEA workshop for infection control practitioners. In the workshop, the practitioners concentrated on high-risk clinical processes that relate to the prevention of infection, particularly in hospital settings.

Through the workshop, the infection control practitioners learned the value of having crystal clear policies and processes related to infection prevention and being sure that all healthcare professional staff members caring for patients carry out the processes properly. We are pleased that the infection control practitioners found the FMEA approach helpful for their roles.

Back to top of page