Achieving a safer health service: Part 3. Investigating root causes and formulating solutions.
The third paper in our series describes the National Patient Safety Agency's approach to investigation, root-cause analysis and significant event audit. When should an investigation be high level and when should it be low level? What does this mean, and how can lessons be translated into safety solutions in local areas? Central initiatives such as patient-safety alerts are also examined.
Woodward
Suzette
S
National Patient Safety Agency, London.
D006801:Humans; D008485:Medical Audit / Q000379:methods; D011785:Quality Assurance, Health Care / Q000379:methods*; D017751:Safety Management / Q000379:methods*; D013192:Staff Development / Q000458:organization & administration; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom