Root cause analysis applied to the investigation of serious untoward incidents in mental health services

Abstract

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.