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To use the DaRhonda Vaught case as an example, it was alleged manually overriding the electronic prescribing cabinets were a common practice due to persistent software problems. This led to a lethal consequence as she administered the wrong medication. Incidents like these cannot be blamed on one individual as this was common practice amongst other staff. Rather than blaming the individual, the poor culture of leadership needs to be addressed. Introducing solutions such as educational seminars on improving team culture, leadership and preventing complacency may be effective in reducing the recurrence of these events.

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To use the DaRhonda Vaught case as an example, it was alleged manually overriding the electronic prescribing cabinets were a common practice due to persistent software problems. This led to a lethal consequence as she administered the wrong medication. Incidents like these cannot be blamed on one individual as this was common practice amongst other staff. Rather than blaming the individual, the poor culture of leadership needs to be addressed. Introducing solutions such as educational seminars on improving team culture, leadership and preventing complacency may be effective in reducing the recurrence of these events.

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A broader bigger picture view might be required across the organisation to aggregate data and identify trends/patterns. This strengthens evidence for implementing improvements in certain problem areas rather than dealing with incidents in isolation, and allows for better targetting of resources for patient safety.

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One of the main problem is RCA is poor design and implementation. Even if the reasons for errors are identified if there is not proper design and implementation system., errors cannot be corrected and prevented. One of the reason is poor resources like staff shortage which cause poor education and training. As a manager I would more focus on staff development, education and training which helps to prevent incidents 

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One of the main problem is RCA is poor design and implementation. Even if the reasons for errors are identified if there is not proper design and implementation system., errors cannot be corrected and prevented. One of the reason is poor resources like staff shortage which cause poor education and training. As a manager I would more focus on staff development, education and training which helps to prevent incidents 

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It's clear in RACFs that RNs to initiate incident report, analyse cause, identify types of incident, open disclosure and interventions to improve and/or prevent happen in future. Care manager review and finalize the report. 

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It's clear in RACFs that RNs to initiate incident report, analyse cause, identify types of incident, open disclosure and interventions to improve and/or prevent happen in future. Care manager review and finalize the report. 

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To establish a just culture in workplace. To educate staff incident reporting is not to blame staff who make errors, instead, it provides opportunities to learn, improve and prevent such errors in future.

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To establish a just culture in workplace. To educate staff incident reporting is not to blame staff who make errors, instead, it provides opportunities to learn, improve and prevent such errors in future.

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To establish and maintain a just-culture in workplace, the consumers and other representatives are involved in incident reporting procedures.

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To establish and maintain a just-culture in workplace, the consumers and other representatives are involved in incident reporting procedures.

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RCA is to analyze the fundamental cause while the error always have more than one causes.

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RCA is to analyze the fundamental cause while the error always have more than one causes.

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Establish a team with a limited number of members within and outside of the health care organization. Address the internal issues firsts, then connect them with broader problems outside of the organisation and reach a consensus of a reasonable number of causes of error.

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Increasing learning from feedback- utilising incidents or events as a case study or discussion forum within the unit/service. Normalising this review and discussion as a unit/service, encouraging openness and transparency

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when individuals are responsible for an adverse event, instead of blaming them, go in the direction of working with the person to improve their care, work with them to organise ways to prevent other people from making the same mistakes. Use and encourage a system approach.

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make incident training mandatory across the state and include in the training ways to include consumers

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The criticism of RCAs by Diller et al. (2014, p. 181) of focusing on who did what as opposed to why the error occurred means that even if the person responsible is singled out the reason as to why it occurred in a wider context is not explored.

Focusing on why the error occurs as opposed to who caused the error would more likely contribute to the analysis of possible wider systems issues.

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If the design is poor and the implementation is not appropriate then it will be unsuccessful. Staff will not understand how or why they are using the tools and the reason why. Rolling out new tools requires all staff to comprehend what is taking place, and proper education around the system.

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This idea may be easier for an inpatient setting. To create some independence from organisation when reviewing, a system could be created where a manager, who is separated from the particular setting/culture, can review the issue. A criteria can be set in terms of what feedback is provided to the department, and this criteria would be consistent across the organisation. Managers and departments can be randomly selected and the load is shared around.
This may help (or hinder) a manager's workload and provide outsider thoughts and recommendations. It may also reduce costs by not contracting the work out to a completed independent company. However, room for bias is still available

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An extra step that feedback is analysed to determine where and how it can be implemented, and to determine the relevance to the systems being analysed. The same sort of mindset that we apply to the concept of universal healthcare - lets make sure it's appropriate and the objective accessible prior to applying it.

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Ensure the consumer is always included in the analysis of the event  - but not just in the investigation of "what happened" but in the change ideas.
Further to consumers, make recommendations for change ideas measurable to be able to link changes to improvement (not all changes will improve the system and should be measured for impact which enables ongoing improvement in system safety.

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As stated and also in agreement, the RCA terminology signals to a single root cause when there could be multiple parts that have lead to an event. I suggest maybe 'Analysis of key causes' (AKC) could be more suitable.