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Reassuring staff that the RCA is aimed at identifying gaps in practice to ensure there is safety and not towards the individual will go a long way in eliminating the blame culture.

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I think that mangers could start by actually giving the feedback to staff, especially in areas where the original incident took place. Then, possibly as a team, the unit could deconstruct the results and pick up the areas that they feel they could collectively improve in and an education plan could be made. It is rare in my experience that the results of root cause analyses are shared with staff at the 'sharp end' so it would be helpful to actually know what an investigation found in the first instance.

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In my facility, the DONM, DMS and GM need to 'sign off' on the recommendations. If a recommendation is perceived to be 'too hard' (usually anything to do with staffing) when it doesn't get approved - deemed 'not achievable.' This is very frustrating as the team put a significant amount of work in to identify the root cause and influencing factors that have led to the recommendation.

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Establish executive 'buy in' early to ensure that the 'bigger issues' can be successfully implemented

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I agree that all participants on an RCA team should be provided with education and training.
- Ash McHugh

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We have seen in Annie’s video from the current module that “problem of too many hands” such as equipment design can be addressed by organisations with strong leadership.

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As part of the RCA methodology, invite an impartial facilitator who will not buy-in to politics and who is capable of redirecting the discussion when needed.
Bec

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Adopt and follow a standardised methodology for design and implementation, which starts with reviewing the last RCA to see what has changed.
Bec

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Invite plurality of causes and encourage broad consideration by renaming it Root Causes Analyses & Action.
Bec

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Specially trained teams lead the process with staff who come from multidisciplinary roles and who are not directly involved in the specific scenario.
//Sissa

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//Sissa

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Amanda
Instead of seeking an individual at the end of the system failure to blame the system that the individual operates in and the circumstances that the system forces an individual into should be examined and causation at this level considered so that the fix is applied at the right point(s).

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Knowing that this single approach only looks at one event at one location, impacts on the institutions ability to learn and develop from the errors that occur. As a manager, researching other institutions errors and their outcomes will improve outcomes within the institution. It gives a greater range of knowledge, skills and tools to use while investigating errors especially within small institutions.

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Before participating in a root cause analysis, the members must have training (such as an e-learning module) in the fundamentals of human factors and ergonomics.

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feedback from the errors is often not communicated well in many of the settings.As a manger discussing the system failure ,consequences and actions taken to prevent such failures will have great impact .