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Sammanfattning

The root cause analysis method is applied when analysing serious accidental incidents. This analysis answers the following ques-tions: What happened?, Why could it happen? How do we prevent it from happening again? The individual analysis is carried out by an interdisciplinary team with participants either directly or indirectly involved in the actual incident. The management of the unit or of the hospital must always be represented on the team, as the analysis will bring about proposals for change in order to optimize the safety systems within the unit and/or the hospital. Decision-making competence is therefore required. Data collection, preparation and report writing is the responsibility of a risk manager, who is trained in the methodology and is conscious of patient safety. Nurses who have taken part in root cause analyses are satisfied that the method provides an opportunity to carry out a factual review of an incident, in which a patient has suffered accidental injury as the result of examination, treatment or care. The root cause analysis supplements learning from a specific incident, but is also part of the creation of a culture, in which patient safety becomes part of the day-to-day routine.

MeSH