INC-SOP-001: Root Cause Analysis of Serious Incidents

At a glance

• Classify the incident as serious (death, severe harm, or a near miss with high potential) within 2 working days.
• Form a review team with no one directly involved in the event.
• Find the causes, not the person to blame: use the root-cause method.
• Write actions with owners and dates. Track them until closed.
• Share the findings with staff and, where appropriate, with the patient or family.
• Stop and get help straight away if: a serious incident is not reviewed within the time set, or the review blames an individual without looking at the system.

Step 1. Classify and register the incident.

• Within 2 working days, the chief executive or delegate classifies the event as serious or not.
• Enter it on the incident log with the date, the classification and the reviewer.

Key point: Classification decides the level of review. Make it early.

Step 2. Form the review team.

• Include a clinician, a manager from another service, a quality lead and, where possible, a patient representative.
• No one directly involved may lead the review.

Key point: Independence is what makes the findings believable.

Step 3. Gather the facts.

• Collect the records, timeline, equipment logs, rotas and communications.
• Interview the people involved, one at a time, in a neutral setting, and record what each person says.
• Build a timeline of events with times.

Key point: A timeline shows what happened in order. Gaps in it are questions to answer.

Step 4. Find the root causes.

• Use the five whys or a fishbone diagram to move from what happened to why.
• Ask whether the system allowed the error, made it likely, or failed to catch it.
• Agree the root causes as a team and record them on INC-FRM-001.

Key point: Stop when you reach a system cause. Blaming a person is the end of the analysis, not the start of the fix.

Step 5. Write actions.

• For each root cause, write one or more actions that change the system: a checklist, a redesign, training with a check, a change of equipment or staffing.
• Give each action an owner, a due date and a measure of success.
• Rank actions by strength. Prefer changes that remove the hazard over warnings and training alone (EC).

Key point: Training alone is the weakest action. Make the safe choice the easy choice.

Step 6. Track and close actions.

• Enter each action on the tracker (INC-REG-001).
• Review overdue actions monthly with the governing body.
• Close an action only when the measure of success is shown.

Key point: An action is complete when it works, not when it is written.

Step 7. Share and report.

• Share the findings and lessons with staff in the affected service.
• Report the outcome to the governing body and, where appropriate, to the patient or family.

Key point: The lessons only help if people hear them.