September 11, 2018 | Mark Paradies

The UK General Medical Council Shows a Lack of Understanding of Root Cause Analysis

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Here is a quote from an article in

“The GMC says human factors refers to the ‘environmental,
organisational and job factors – and human and individual
characteristics – which influence behaviour at work in a way
that can affect health and safety,’ while root cause analysis

is a systematic process for identifying ‘root causes’ of problems
or events and an approach for responding to them.

Responding to the review, the GMC said: ‘Focusing on root cause analysis
may not always be the best way of dealing with all investigations
and we understand that exploration of a human factors approach
is underway at several NHS Trusts in England.'”

To use an “English” term …

“What rubbish!”

Who gave this team of senior managers the idea that human factors is not a part of a root cause analysis?

If they aren’t including human factors, behavior, organizational factors (Management Systems), procedures, training, communications, work direction, and quality processes in their root cause analysis … THEY AREN’T DOING ROOT CAUSE ANALYSIS THE RIGHT WAY.

Instead of trying “human factors,” they should try a root cause analysis system that automatically includes “human factors,” the TapRooT® Root Cause Analysis System.

Find out more about how TapRooT® includes human factors at:

Why did they decide they needed to change? Because their system exhibits a blame culture and abysmal root cause analysis. A particle case involving Dr. Bawa-Garba finally got senior leadership to admit that they need to improve. But instead of finding out what is wrong with their practices, they decided they needed a new buzzword … human factors.

We have written several articles about root cause analysis practices in the UK and the need for improvement, including Dr. Death and Half a Million Blunders, but after all this time, little improvement has occurred.

Will a new focus on human factors solve the problems of the UK National Health System? Doubtful. Good root cause analysis (that includes human factors, among other things) and implementation of appropriate corrective actions could have solved these problems years ago. I would guess that:

  • poor root cause analysis,
  • unwillingness to change,
  • understaffing and budgeting,
  • poor Management Systems, and
  • bureaucracy,

will continue to haunt NHS patients no matter how many human factors courses are given to hospital staff members.

NHS senior leadership must understand what is wrong (through advanced root cause analysis) and be willing to make change happen BEFORE real improvement will occur.

Contact us (CLICK HERE) if you are committed to making root cause analysis (that includes human factors) work at your facility or company.

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