ABSTRACT
Hospitals and other healthcare providers have a duty by law to investigate serious adverse events and many organisations operate incident reporting systems. Most healthcare providers choose Root Cause Analysis (RCA) to generate learning from incidents. RCA is the accepted approach to deliver this, but other methods could be used if an organisation wanted to make an argument for it. RCA aims to clarify what happened, identify contributory factors, and develop recommendations for improvement to practice. This chapter draws upon the author's experiences from a six-year project called Safer Clinical Systems (SCS). The SCS project was funded by the Health Foundation, a UK charity. The overall aim of SCS was to co-design and test a systems-based approach to patient safety improvement, largely inspired by safety management practices from safety-critical industries. The approach included the systematic identification and assessment of risks and the development of a safety argument documented in a safety case.
