Root Cause Analysis in Practice: Investigating Clinical Incidents
Run a defensible investigation that finds system causes instead of a person to blame.
Program overview
Root cause analysis fails in predictable ways: it stops at the sharp end, it confuses sequence with cause, and it produces recommendations nobody can implement. This course teaches a disciplined method — timeline construction, contributory factor analysis, the five whys used properly, fishbone mapping — and the judgement to know when each is appropriate. You will work through a full investigation from notification to report, including how to interview staff involved in an incident without re-traumatising them, and how to write recommendations that are specific, owned and testable.
Why this program
A complete method from notification to closed action
Teaches interviewing that does not re-traumatise staff
Recommendations that are specific, owned and testable
Covers the common ways RCA goes wrong
Who it is for
Program objectives
- Describe when root cause analysis is and is not the right tool
- Construct an accurate incident timeline from mixed sources
- Apply contributory factor frameworks to a clinical event
- Conduct a supportive interview with staff involved in an incident
- Differentiate contributory factors from root causes
- Write recommendations that are specific, assigned and measurable
Learning outcomes
- Construct a defensible timeline from a set of incident records
- Apply a contributory factors framework to classify identified issues
- Differentiate proximate cause from underlying system cause
- Plan an interview approach for a distressed staff member
- Evaluate a set of draft recommendations against the effectiveness hierarchy
- Document an investigation in a format suitable for governance review
Curriculum
Module 1: When RCA Is the Right Tool
1 lessonsWhen RCA Is the Right ToolPreview
Thresholds, alternatives and the cost of over-investigating.
Module 2: Building the Timeline
1 lessons- Building the Timeline
Module 3: Contributory Factor Analysis
1 lessons- Contributory Factor Analysis
Module 4: Interviewing After an Incident
1 lessons- Interviewing After an Incident
Module 5: From Findings to Recommendations
1 lessons- From Findings to Recommendations
Module 6: Reporting and Follow-Through
1 lessons- Reporting and Follow-Through
Duration and structure
6 lessons across 6 modules. Duration is expressed in study hours.
What you receive
This certificate confirms completion of Root Cause Analysis in Practice: Investigating Clinical Incidents. Duration is expressed in study hours.
Delivery format
- Self-paced — start any time.
- Study on any device.
- Lifetime access to the version you enrolled in.