Root Cause Analysis Conference: Investigating & Analysing Patient Safety Incidents

The aim of this conference is to drive improvement in the effective use of RCA investigation, ensuring its full potential is harnessed in order to inform learning and measurable patient safety improvement. The opening session delivered by Donna Forsyth, Head of Patient Safety Investigation at NHS England will update delegates on core principles for an effective root cause analysis, triggers you should be using and putting theory into practice from a national NHS England perspective. The day will continue with extended expert legal session which will focus on developing your skills in Root Cause Analysis looking particularly at improving your methods, techniques and report writing skills. Kate Hill has been advising organisations on Root Cause Analysis for over 10 years and will share her experience of what works, what doesnt and the common mistakes and pitfalls she sees in investigation report writing. Practical case studies will look at identifying the appropriate level of investigation and training and educating frontline staff in Root Cause Analysis.

A “How we did it!” extended focus will include case studies from organisations on a step by step guide to undertaking RCA’s for falls and for pressure ulcers. The following sessions will develop the theme of ensuring change occurs and the lessons are learnt as a result of the investigation. The conference aims to bridge the gap between theory and practice and developing your skills in using high quality root cause analysis to investigate patient safety incidents and drive changes in practice.