Final Report > Chapter 26: The Safety of Care > Overcoming the barriers to openness > Acting on reports

Acting on reports

42 The trust, in receipt of reports from staff, must act. All sentinel events should be subject to a form of structured analysis which takes into account the wider factors within the organisation which may have given rise to the event, as well as the conduct of individuals. This analysis is best done within the organisation in which the event occurs and as close as possible to the time of the event. We have in mind and commend something akin to the process of `root cause analysis'. Borrowed from the world of engineering, this process allows all of the factors which might have contributed to an event to be identified and analysed. It was recently advocated by the DoH [33] and has been used successfully for some years in the USA by the Joint Commission for the Accreditation of Healthcare Organisations. The analysis in turn forms the raw material for a plan of action designed to address the failures or omissions which have been identified.

Footnotes

[33] `Building a Safer NHS for Patients', April 2001, p. 38, Department of Health. www.nhs.org.uk