Table 5

Inclusion of contributory factors and follow-up in root cause analysis

Root cause analysis contentNumber, n=140 (%)
All individual contributory factors listed18 (13)
Some factors using National Patient Safety Agency headings15 (11)
Some factors using different headings5 (4)
Mixed headings7 (5)
Summary only45 (32)
No contributory factors50 (35)
Actions (or recommendations/learning points)123 (88)
No actions17 (12)
Systemic actions111 (79)
Systemic and individual actions12 (9)
Non-clinical actions only9 (6)
Timeline and person responsible identified77 (55)
Audit19 (14)