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Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices
  1. L M Wallace1,
  2. P Spurgeon2,
  3. S Adams3,
  4. L Earll4,
  5. J Bayley1
  1. 1
    Applied Research Centre Health & Lifestyles Interventions, Coventry University, Coventry, UK
  2. 2
    Institute of Clinical Leadership, West Midlands Deanery, Birmingham, UK
  3. 3
    Sally Adams & Associates, Northampton, UK
  4. 4
    Researchthatworks Limited, Gloucester, UK
  1. Professor L M Wallace, Applied Research Centre Health & Lifestyles Interventions, Coventry University, Whitefriars, Prior Street, Coventry CV1 5FB, UK; l.wallace{at}


Background: Root Cause Analysis (RCA) is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems. The National Patient Safety Agency (NPSA) in England and Wales commissioned a survey evaluation of its national training programme which consisted of 3-day workshops and internet support materials.

Methods: Anonymous survey of 374 health professionals immediately after they attended the programme (T1), and a further 350 participants 6 months after the programme (T 2), who had attended courses in England and Wales in 2005.

Results: T1 knowledge tests showed a greater understanding of the frameworks and techniques of RCA but with less accuracy in application to scenarios. Personal beliefs about conducting RCAs were consistently positive at both times, but many participants experienced personal barriers to conducting RCA in their current role and trust context, and some felt low confidence in undertaking cascade training of other staff in their trust. There was also low confidence in implementing RCA as standard practice at both times. At T2, 76.7% were confident the outcomes from their RCA had been implemented, but only 12.1% were aware if improvements had been shared outside the local organisation. Barriers to RCA at both times most often concerned time and resources to apply RCA. At T1, there was particular concern for personal development, at T2 greater concern for organisational impediments.

Conclusions: The RCA programme enhanced knowledge of RCA, and participants valued the programme, but further personal development and organisational support are required to achieve continued improvement in practice and sustained organisational learning.

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  • Additional appendices are published online only at

  • Funding: The research was funded by the Department of Health’s Patient Safety Research Programme.

  • Competing interests: None.

  • Ethics approval: The study was approved by a multicentre research ethics committee (MREC Wales, MRE09/47).

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