1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ RCA Report Writing

2. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Gathering Information & Mapping the Incident Identifying Care & Service Delivery Problems Analysing Problems & Identifying CFs and RCs Generating Solutions & Recommendations Implementing Solutions Writing the Report Getting Started The RCA Process

3. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Who may expect to see the Report? Write one report with all audiences in mind... Patient or relatives and carers Health Boards Health Board Management Committees Welsh Assembly Government Welsh Risk Pool Coroners Office Solicitors Local or National Media General Public

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Purpose of the Report The purpose of the report is to provide: a formal record of the investigation process a means of sharing learning The report presents the culmination of all the work undertaken by the investigation team. It should convey all necessary information about the incident, the investigation process and the findings. The audience will use the content, style and tone of the report to judge: the quality of the investigation process, findings, conclusions and recommendations the competence of the investigation team

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Style and Format Use the NHS investigation report template for layout and style Keep it clear, logical and demonstrate an open and fair approach Avoid negative / inflammatory descriptors Use plain English - and avoid jargon and acronyms If you need to use technical terms include a Glossary Write in the third person (e.g. refer to ‘the patient’, ‘the doctor’, ‘the organisation’, rather than ‘I’, ‘we’ or ‘you’) Present the patient(s) or staff involved as individuals - without being overly personal or compromising confidentiality.

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Content and Findings Whilst a report must be evidence-based and not move into speculation, investigator(s) are required to do more than simply summarise findings. Analysis, deduction and recommendations are required. Terms such as ‘from the evidence it was concluded’ are useful for distinguishing analysis from evidence. Source material, evidence, and theories which back up analysis should be appropriately referenced. Prior to final release, the author must arrange proof-reading and checking for factual accuracy, grammar and spelling.

7. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Confidentiality In a report for learning there is no need to identify the staff or patients involved in the incident If you use a code (e.g. Mrs S, Dr A and Nurse Y), keep the key with a secure archive copy of the report. (Those involved have a right to request the key) Ask the patient / family how they want the patient referred to in the report. (They may ask to be named if this doesn’t inappropriately identify others)

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Web-based RCA Report Writing toolkit 1.RCA Templates - To record and share your findings e.g. RCA investigation report template Contributory factors grid Action plan 2. RCA Tools - To help with the investigation process e.g. Triggers for RCA investigation Change analysis tool Options appraisal / Impact analysis 3. RCA Guidance - Background info and ‘how to’ guides e.g. Guide to investigation report writing Three levels of RCA investigation Investigative interview guidance www.npsa.nhs.uk/rca

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Better root cause analysis 1.Clearly show cause-and-effect relationships in your analysis i.e. All causes listed must lead to the incident/effect on the patient otherwise they are lessons learned or not relevant to this incident 2.For every error or omission state the contributory factor or cause (e.g. clinician violated the procedure because it was the local norm) (e.g. clinician missed a step in the procedure because they were doing the task by memory instead of using the existing checklist) 3.An error or omission should only be attributed to a person or a service if they had knowledge of the issue and / or a responsibility to act. VA National Center for Patient Safety: Using the Five Rules of Causation

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Report Writing Templates Comprehensive and Independent Investigation Report template RCA Tools Concise Investigation Report template for No & Low harm investigations for Internal and externally commissioned Death and Serious harm investigations

11. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ WAG Guidance on reporting and handling of serious incidents and concerns -June 2010 Concise Investigation Report Template Also available with ‘quick reference guidance’ as required - www.npsa.nhs.uk/rca

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ WAG Guidance on reporting and handling of serious incidents and concerns - June 2010 Comprehensive Investigation Report Template Also available with quick ref. guidance as required - www.npsa.nhs.uk/rca

13. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Comprehensive Investigation Report Executive summary (1-2 pages maximum) Full report Action plan Appendices Concise Investigation Report One page report with action plan Identical format to executive summary of a full report

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Appendices of full report Suggested inclusions: List of literature reviewed List of evidence gathered Copies of key documents, site plans, photographs etc Final chronology or timeline Templates used for analysis (e.g. fishbones, run charts, change / impact analyses) Lessons learned log Acknowledgements (if part of NHS organisation style and format).

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Driving up credibility, thoroughness and ability to learn from investigations Full guidance on RCA Report Writing www.npsa.nhs.uk/rca

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ RCA Tracking and Evaluation Tool www.npsa.nhs.uk/rca

17. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ RCA Tracking and Evaluation Tool

18. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Types of RCA investigation RCA Aggregation - Narrow themed investigations/reviews www.npsa.nhs.uk/rca

19. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Collection & Sharing of RCA findings National PSI dataset and reporting since ‘03 Next steps... Standardise RCA data collection (dataset) Begin RCA reporting to the NRLS for analysis Facilitate shared learning

20. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key Points – Report writing If you only remember one of the RCA Report tools choose the Report Writing Template Write the report once, for whoever may need to see it Aggregate RCA findings for learning Involve the patient and relatives for new learning

21. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ (From – ‘Essentials of successful complaints management’)... RCA Works equally well for complaints and claims Express Regret Find Reason Apply Remedy Investigations in summary...

22. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ After attending this event, and using the knowledge, skills and resources gained, delegates should be better able to:- Outline and discuss the theory underpinning RCA Investigation Describe and promote effective investigation process Lead and conduct credible, thorough and proportionate RCA Investigations Learning Outcomes ?