From Root Cause Analysis to Systems Thinking: A Comparative Content Analysis of Patient Safety Incident Investigation Reports in Mental Healthcare.

rationaleThe National Health Service, UK, has recently implemented a new patient safety strategy, replacing root cause analysis (RCA) incident investigation with systems-based approaches. It is unknown if this change will optimise learning and improve care outcomes. AIMS

objectivesWe aimed to analyse safety recommendations/actions/improvements/solutions from comprehensive incident investigations by comparing those that adopted root cause analysis with systems-based approaches.

methodThe evaluation adopted a sequential multi methods design. Reports were extracted between January 2022 and January 2023. The quality of the incident investigation was graded using a validated tool (Learning Response Review and Improvement Tool). Investigation identified solution types were organised using qualitative content analysis, adopting inductive and deductive orientations. These were then classified into system factors and the effectiveness of the solution scored. Descriptive statistics were computed to investigate differences between incident investigation type.

resultsGrading the quality of reports demonstrated that the expectations set out within the change in safety strategy were mostly being realised in practice. A total of 135 solutions were extracted from systems-based and 57 from RCA reports, where the type of solutions identified were similar between each investigation approach. Organisational system factors were the most frequent for systems-based whilst task system-work factors were most frequent for RCA reports. For both investigation types, most of these solutions were deemed to fall in the least effective category: administrative controls.

conclusionThe evaluation provides important insights into how the shift to systems-based investigations are shaping the quality of investigations and the recommendations that aim to prevent a recurrence of harm. Changing from RCA to systems-based investigations led to more patient/carer/family involvement and systems-focussed solutions, however weaker administrative recommendations remained prominent. Policy, practice and research need to ensure that the change in conceptual thinking and investigative orientation also contributes to improvements in learning and the development of stronger controls or barriers that prevent harm.