Learning from incidents and investigations

  • Root Cause Analysis (RCA) investigation Every day a million people are treated safely and successfully in the NHS. However, when incidents do happen, it is important that lessons are learned to prevent the same incident occurring elsewhere. RCA is a well-recognised way of doing this. Investigations identify how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for our patients.
  • The National Patient Safety Agency (NPSA) RCA Investigation resources  provides or links to all of the good practice tools and templates
  • The Serious Incident framework; the National Framework for Reporting and Learning from Serious Incidents Requiring Investigation can be found here –
  • NHS England Independent investigation reports