October 14, 2019 | Mark Paradies

UK NHS’s New Term: “Systems-Based Patient Safety Investigation” (= Root Cause Analysis)

Systems-Based Patient Safety Investigation = TapRooT® Root Cause Analysis

Why do I say that Systems-Based Patient Safety Investigations = TapRooT® Root Cause Analysis? We’ll get to that in a minute. Let’s start with the fairly new NHS Patient Safety Strategy (published July 2019).

NHS Patient Safety Strategy

First, let’s talk about how the new NHS Patient Safety Strategy impacts the root cause analysis of patient safety-related incidents in England. In December of 2018 NHS Improvements said:

“We know there are problems, for example, with how incidents are investigated and learned from. In our recent engagement to find out how we can improve the Serious Incident framework, people told us they were concerned about: providers’ lack of capability and capacity to carry out good quality investigations; the tendency to use investigation for the wrong purposes; the generally poor approach to patient and family involvement; and the fact that actions to reduce risks after the completion of an investigation are too often ineffective. We know from the Care Quality Commission’s (CQC’s) review of how the NHS responds to and learns from the care provided to patients who die that too often problems with care are not identified and the bereaved, who may have concerns, are not sufficiently supported.”

In response to numerous patient safety incidents, negative press coverage, and political pressure, the NHS produced a new Patient Safety Strategy. This strategy includes a proposal to develop a new Patient Safety Incident Response Framework. The projected schedule for developing this framework is (from NHS Improvements, July 25, 2019):

  • Autumn 2019 – PSIRF published as introductory guidance and NHS England and NHS Improvement begin work with a small number of early adopters.
  • From Autumn 2020 – local systems and organizations outside of the early adopter areas will be encouraged to move across to the new framework.
  • By Summer 2021 – all parts of the NHS in England expected to use PSIRF.

The first part of this development was the introduction of new terminology proposed in the NHS Patient Safety Strategy. The strategy set forth the following terminology:

Terminology: making references to ‘systems-based patient safety investigation’, not ‘root cause analysis’, to reflect the ‘systems’ approach to safety.

But what was wrong with the old way that the NHS performed root cause analysis? The NHS Improvement document, The Future of NHS Patient Safety Investigation, said:

…CQC [5] found that only 8% of the investigation reports it reviewed showed evidence of a clearly structured methodology that identified the:
• key issues to be explored and analysed
• contributory factors and underlying system issues
• key causal factors that led to the incident.

One of the most common issues is disproportionate focus on some of the activities associated with the first two phases of the investigation process (that is, setting up the investigation and gathering information; see Appendix 1), and not enough focus on many of the essential activities required as part of the later phases (that is, the analysis of problems and identification of key contributory factors) [10]. Consequently, investigations often use relatively limited sources of information – such as clinical notes and written statements – to establish what happened. Based on this, they make inappropriate conclusions that typically concentrate on judgements about avoidability, preventability or predictability, which is not the purpose of a safety investigation (as described earlier).

In addition, and with reference to issues associated with time and pressures from the wider system, investigators are often asked to conduct RCAs to satisfy the needs of many stakeholders. This can lead to a conflict of purpose when issues such as liability, professional performance and cause of death are considered in the same report.

That sounds like the reasons for developing TapRooT® Root Cause Analysis when we started researching how to develop an advanced root cause system back in the 1980s. And that’s probably why the NHS’s revised Serious Incident Framework includes the following principle:

Investigations identify and act on deep-seated causal factors to prevent or measurably and sustainably reduce recurrence.

TapRooT® Root Cause Analysis and System-Approach to Safety + Human Factors

Since TapRooT® Root Cause Analysis has always included the “systems” approach to safety, that means that Systems-Based Patient Safety Investigations = TapRooT® Root Cause Analysis Investigations.

But there are more in the similarities of TapRooT® Root Cause Analysis and where the NHS wants to go with patient safety improvement. In the survey that was the basis for the NHS Patient Safety Strategy, a question asked was:

Which areas do you think a national patient safety curriculum should cover?

The most frequently cited response was:

Human factors and ergonomics (297 respondents)

What was the basis for developing the TapRooT® Root Cause Analysis System? To bring human factors/economics knowledge to investigators with little or no human factors training. We wanted to help investigators go beyond identifying “human error” as a root cause and find the real. fixable root causes of human error. For more information about this, see:

Is Human Error a Root Cause?

Or watch this video series:

The video was based on my 2019 Global TapRooT® Summit talk:

How to fix human error…

That is outlined in the link above.

New TapRooT® Books and Courses

And this talk led to a new book and a new course that will be coming out early next year. (Watch for more information about it in upcoming articles).

But patient safety professionals don’t have to wait. They can get new ideas and a great investigation process for patient safety incidents in the book:

Improve Patient Safety with TapRooT® Root Cause AnalysisImprove Patient Safety with TapRooT® Root Cause Analysis

Patient safety professions, don’t wait to get started. Order the book above and get started now! Then, sign up for a TapRooT® Root Cause Analysis Course. See our upcoming public course dates and locations at this link:


Or sign up for our special course being held prior to the 2020 Global TapRooT® Summit:

TapRooT® Root Cause Analysis for Patient Safety Improvement


Patient Safety & Healthcare, Root Cause Analysis
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