Training activity information
Details
Investigate an incident and perform a route cause analysis, including document findings and outcomes
Type
Developmental training activity (DTA)
Evidence requirements
Evidence the activity has been undertaken by the trainee​.
Reflection on the activity at one or more time points after the event including learning from the activity and/or areas of the trainees practice for development.
An action plan to implement learning and/or to address skills or knowledge gaps identified.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What do you know about the principles and methodologies of RCA?
- What constitutes an incident in a diagnostic laboratory setting? What are the key steps involved in performing an RCA?
- What tools and techniques can be used for RCA (e.g., 5 Whys, fishbone diagram)?
- What is the process for documenting findings and outcomes of an incident investigation and RCA?
- Discuss with your supervisor the specific incident you will be investigating and the scope of the RCA.
- Consider different potential root causes and how you might investigate them. Reflect on your current understanding of RCA principles and documentation requirement.
In action
- Describe your current steps in the investigation (e.g., gathering information, interviewing staff, reviewing records). Why are you following this particular line of inquiry? When performing the RCA, what method are you using (e.g., 5 Whys, fishbone diagram)? Why did you choose this method?
- What decisions are you making about the potential contributing factors and the root cause of the incident?
- How effectively are you gathering relevant information and identifying potential causal factors?
- What challenges are you encountering in the investigation (e.g., incomplete information, conflicting accounts) or in identifying the true root cause?
- What are you learning about the specific incident and the factors that contributed to it as your investigation progresses?
- Are there alternative approaches you could take to gather more information or to analyse the potential root causes?
- What support or input might you need from colleagues or supervisors during the investigation and analysis?
- Are you ensuring that your investigation and analysis are objective and focused on identifying the underlying causes rather than assigning blame?
On action
- What was the incident that was investigated? What steps were involved in performing the route cause analysis (RCA)? What were the key findings and identified root causes of the incident? What were the proposed actions or outcomes documented following the RCA?
- How has your understanding of incident investigation and route cause analysis improved? What did you learn about the process of identifying contributing factors and root causes of errors or incidents in a laboratory setting? How did this experience enhance your understanding of the importance of documentation and implementing corrective actions? What did you learn about the application of quality standards in addressing and preventing incidents?
- What specific aspects of incident investigation or RCA methodology do you need to develop further? How will you apply your learning to future situations involving incidents or errors? What actions will you take to strengthen your skills in performing RCA and documenting findings? What resources or training would be helpful for your continued development in this area of quality management?
Beyond action
- Have you been involved in investigating other incidents or errors since this DTA? Did you apply the principles of route cause analysis in those situations?
- Have you had opportunities to review the outcomes of other incident investigations and the effectiveness of the implemented corrective actions?
- Reflecting on your ‘reflect-on-action’, were the proposed actions from your RCA implemented, and what was their impact?
- Has your understanding of incident investigation and route cause analysis made you more aware of potential risks and errors in the laboratory?
- Are you more confident in identifying contributing factors and proposing effective solutions when issues arise?
- How has this experience contributed to your understanding of the importance of a proactive approach to quality and safety?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 4 |
Outcome
Analyse, interpret and prepare interpretive reports for common haematological malignancies, including results for somatic variants, clonality, and somatic hypermutation. |
| # 5 |
Outcome
Interpret the associated IQC and EQA of the laboratory tests for investigation of haematological malignancies. |
| # 6 |
Outcome
Practice with the relevant specialties for the diagnosis, monitoring and management of haematological malignancies. |
| # 8 |
Outcome
Apply the standards of ISO:15189 accreditation and compliance including root cause analysis (RCA) and verfication/validation requirements for cancer genomics. |