Training
Two trainers from the Training Center of the UMC Utrecht and the patient safety coordinator attended a RCA training in England. Using this experience, together with the literature on RCA and experience from international contacts, they created a Dutch version of RCA. This was piloted during several months. The Training Center then set up a two day Dutch RCA training.
The UMC Utrecht is divided into 12 divisions (surgery, internal medicine etc). The hospital management asked all divisions to send at least two people to the training. From each division two to four nurses and physicians were chosen by the division management. The training started with an introduction to patient safety and human factors engineering. Each participant was asked to bring along an incident which he or she had heard of or been part of. The different steps of RCA were explained and the trainees practiced each step using role playing based upon one of their own incidents.
Eventhough most trainees had no idea what they had been sent to and some were outright sceptic at the start, at the end all attendees were enthousiastic about RCA and gave very high marks in the evaluation form.
Organisation
The UMC Utrecht, as all hospitals in the Netherlands, has a central Incident Reporting Committee (IRC). All incidents that are reported go to the IRC for evaluation and filing.
Before introduction of RCA, serious incidents would be evaluated by a member of IRC without using any particular format of inquiry. This changed after RCA was introduced.
Now, when an incident is reported, the CIRC still decides if the incident should be analysed, but to help them decide, they use a hazard matrix in which the frequency of similar incidents is related to the severity of the outcome. When an incident scores high on the hazard matrix, or if the IRC feels that the incident merits further analysis for any other reason, the decision is made to do a RCA.
The IRC no longer executes the analysis itself, but requests two RCA-trained personnel from the division in which the incident occured to carry out the investigation.
When they have completed the RCA, it is discussed with the patient safety coordinator for a final check. This is to ensure a constant quality of all RCAs and the reports, because many personnel will only do one or two RCAs a year.
The IRC then judges the report and, if it agrees, sends it to the division or hospital management. Management is requested to give a reaction to the conclusion of the report and to specify if and when the suggested improvements will be implemented.