June 10, 2019 | Mark Paradies

Preventable Deaths in UK Healthcare System (Need Better RCA?)

How Many Repeat Patient Safety Related Deaths Are Too Many?

When patient safety and root cause analysis get the attention of politicians, you know there must be a problem.

UK Edgbaston Labour MP, Preet Gill, (above) said:

“This is not the first time and
no doubt it will not be the last because
lessons are not being learned.
That’s my main concern.”

about a series of 11 preventable deaths related to two Uk mental health facilities.

Robust Root Cause Analysis for Patient Safety

The BBC reported that the two UK mental health facilities said that they had performed a “robust root cause analysis” after each death.

That made me think…

If the root cause analysis was “robust,”
why didn’t it work (prevent the next death)?

A sure sign that your root cause analysis program is inadequate is a series of serious accidents or deaths.

And the UK healthcare system isn’t the only place where patient-safety-related root cause analysis is sub-par. Back in May, we published a blog post about patient safety improvement being needed NOW! (Is Visiting a Hospital in Australia Like Playing Russian Roulette?)

Stop Repeat Fatalities

Over 15 years ago I wrote an article entitled, “Stop The Sacrifices” about fatalities in the construction industry. It was very controversial then. Now I’m wondering if I should write something similar about healthcare root cause analysis because,

I just don’t think the healthcare industry gets the idea!

Why 20 years after the report, “To Err is Human: Building a Safer Health System“, that sounded the alarm, is there so little progress in improving patient safety?

If patient safety professionals read the “Fundamentals of Root Cause Analysis,” would they understand what they are doing wrong?

If 100,000 to 200,000 needless patient safety-related deaths in the USA (the range of some of the latest estimates) don’t get people’s attention, what can we do?

What do you think? Should “robust” root cause analysis stop these repeat deaths?

What can we do to communicate what is a thorough, credible, robust root cause analysis to patient safety professionals?

Can we make change happen that will be effective in improving patient safety?

Leave your ideas below in the comments.

Accidents, Current Events, Patient Safety & Healthcare
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