1. RCA Report Writing

2. The RCA Process Getting Started
Gathering Information & Mapping the Incident
Identifying Care & Service Delivery Problems
Analysing Problems & Identifying CFs and RCs
Generating Solutions & Recommendations
Write the Report – Utilise the national template for consistency and thoroughness. Gain Board/Director level ratification. Share findings.
Implementing Solutions
Writing the Report

3. Who may expect to see the Report
Who may expect to see the Report? Write one report with all audiences in mind...
Patient or relatives and carers
Organisation Risk Management Committees
Health Authority
Coroners Office
Organisation Staff
Department of Health
NHS Litigation Authority
Solicitors
Local or National Media
General Public

4. Purpose of the Report The purpose of the report is to provide:
a formal record of the investigation process
a means of sharing learning
The report presents the culmination of all the work undertaken by the investigation team. It should convey all necessary information about the incident, the investigation process and the findings .
The audience will use the content, style and tone of the report to judge:
the quality of the investigation process, findings, conclusions and recommendations
the competence of the investigation team

5. Style and Format
Use the NHS investigation report template for layout and style
Keep it clear, logical and demonstrate an open and fair approach
Avoid negative / inflammatory descriptors
Use plain English - and avoid jargon and acronyms
If you need to use technical terms include a Glossary
Write in the third person (e.g. refer to ‘the patient’, ‘the doctor’, ‘the organisation’, rather than ‘I’, ‘we’ or ‘you’)
Present the patient(s) or staff involved as individuals - without being overly personal or compromising confidentiality.

6. Content and Findings
Whilst a report must be evidence-based and not move into speculation, investigator(s) are required to do more than simply summarise findings.
Analysis, deduction and recommendations are required.
Terms such as ‘from the evidence it was concluded’ are useful for distinguishing analysis from evidence.
Source material, evidence, and theories which back up analysis should be appropriately referenced.
Prior to final release, the author must arrange proof-reading and checking for factual accuracy, grammar and spelling.

7. Confidentiality
In a report for learning there is no need to identify the staff or patients involved in the incident
If you use a code (e.g. Mrs S, Dr A and Nurse Y), keep the key with a secure archive copy of the report.
(Those involved have a right to request the key)
Ask the patient / family how they want the patient referred to in the report.
(They may ask to be named if this doesn’t inappropriately identify others)

8. Web-based RCA Report Writing toolkit
RCA Templates - To record and share your findings e.g.
RCA investigation report template
Contributory factors grid
Action plan
2. RCA Tools - To help with the investigation process e.g.
Triggers for RCA investigation
Change analysis tool
Options appraisal / Impact analysis
3. RCA Guidance - Background info and ‘how to’ guides e.g.
Guide to investigation report writing
Three levels of RCA investigation
Investigative interview guidance

9. Better root cause analysis
Clearly show cause-and-effect relationships in your analysis
i.e. All causes listed must lead to the incident/effect on the patient otherwise they are lessons learned or not relevant to this incident
2. For every error or omission state the contributory factor or cause
(e.g. clinician violated the procedure because it was the local norm)
(e.g. clinician missed a step in the procedure because they were doing the task by memory instead of using the existing checklist)
An error or omission should only be attributed to a person or a service if they had knowledge of the issue and / or a responsibility to act.
VA National Center for Patient Safety: Using the Five Rules of Causation

10. Report Writing Templates
Comprehensive and Independent Investigation Report template
RCA Tools
Concise Investigation Report template
for
No & Low harm investigations
for
Internal and externally commissioned Death and Serious harm investigations

11. Concise Investigation Report Template
Also available with ‘quick reference guidance’ as required -

12. Comprehensive Investigation Report Template
Also available with quick ref. guidance as required -

13. Comprehensive Investigation Report
Concise Investigation Report
One page report with action plan
Identical format to executive summary of a full report
Comprehensive Investigation Report
Executive summary (1-2 pages maximum)
Full report
Action plan
Appendices

14. Appendices of full report
Suggested inclusions:
List of literature reviewed
List of evidence gathered
Copies of key documents, site plans, photographs etc
Final chronology or timeline
Templates used for analysis (e.g. fishbones, run charts, change / impact analyses)
Lessons learned log
Acknowledgements (if part of NHS organisation style and format).

15. Driving up credibility, thoroughness and ability to learn from investigations Full guidance on RCA Report Writing

16. Key Points – Report writing
If you only remember one of the RCA Report tools choose the Report Writing Template
Write the report once, for whoever may need to see it
Involve the patient and relatives for new learning

17. Learning Outcomes Introduction & Overview
After attending this event, and using the knowledge, skills and resources gained, delegates should be better able to:-
Describe the RCA Investigation process
Conduct effective Level 1 Investigations
Support Lead Investigators in Level 2 Investigations
Assist in effective solutions development and implementation of patient safety improvements