Again, with permission, I am posting an example an excellent SABRE report which I wish to share with you as an example of how you might want to approach an investigation.

I'm not posting this as an example of how to investigate a specific type of error, but more to show what can be achieved with a thorough investigation, where the staff involved are accountable, but not blamed for having made a mistake. This report is an excellent example of where staff were encouraged to be open and honest to enable the investigation team to fully identify the root causes and contributory factors. Having identified these RCs, the investigation team were able to identify and implement 28 recommendations which involved re-mapping processes, updating procedures, addressing training deficiencies, etc. In other words, the quality systems were improved instead of concluding that someone missed a step of the process or had a lapse in concentration without further probing.

I am not expecting all further SABRE reports to be 39 pages long, as I hope that most SABRE reports won't require such a thorough investigation, but again I hope it gives colleagues ideas for how to approach a successful investigation.

RCA (anon for MHRA).doc