title: Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.
abstract: BACKGROUND
  Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited.
  
  
  OBJECTIVE
  To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP).
  
  
  OBJECTIVE
  Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety.
  
  
  METHODS
  Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia.
  
  
  METHODS
  Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired.
  
  
  RESULTS
  No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training.
  
  
  CONCLUSIONS
  RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.
authors.affiliation: Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia. j.braithwaite@unsw.edu.au
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Braithwaite
authors.forename: Mary T
authors.initials: MT
authors.lastname: Westbrook
authors.forename: Nadine A
authors.initials: NA
authors.lastname: Mallock
authors.forename: Joanne F
authors.initials: JF
authors.lastname: Travaglia
authors.forename: Rick A
authors.initials: RA
authors.lastname: Iedema
mesh_terms: D006282:Health Personnel / Q000193:education* / Q000523:psychology; D006801:Humans; D007318:Inservice Training / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control*; D009517:New South Wales; D010043:Outcome and Process Assessment, Health Care; D015397:Program Evaluation; D017751:Safety Management / Q000592:standards*; D013597:Systems Analysis