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J Healthc Qual. 2005 Sep-Oct;27(5):11-9.

Learning from unexpected events: a root cause analysis training program.

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University of Utah, USA.


Staff members need appropriate training before the investigation and causal analysis of accidents in any complex system. Otherwise results will be incomplete and will be focused on the Least manageable contributors, such as the unsafe acts of frontline operators, regardless of the degree of organizational commitment. This is particularly true in healthcare, a field in which errors have traditionally been understood in terms of breaches of personal and professional accountability. This article outlines an incident investigation and root cause analysis workshop developed to address this training need for healthcare professionals representing the full spectrum of healthcare settings in Utah and Nevada and reviews feedback from participants.

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