Using root cause analysis tools to understand adverse events is “critical” to improving safety across the NHS, according to chief nursing officer for England Dame Christine Beasley.
“If trusts don’t have the systems in place to develop solutions, such as audit trails and root cause analysis, then the environment becomes inherently dangerous because there is a risk every time you do something,” she told delegates last week at a patient safety conference in London.
Dame Christine said “unacceptable variations” still existed in clinical practice and that trusts needed to develop a “system memory” for adverse events to improve patient safety.
Referring to the ratings in the Care Quality Commission annual health check, she said: “It concerns me that 27 trusts have not moved on from being rated as ‘fair’ [for quality] in the last four years, and that staff in these organisations are really stuck at this level.
“There are some fantastic approaches to care and increasing the safety of services [in the NHS], but there is no doubt we still have too much variation in the system. This increases error, decreases quality and increases costs,” she said.