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INTRODUCTION: Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to investigation is root cause analysis (RCA); however, such an approach does not prioritize system-focused action generation. Learning team-based investigations are thought to generate more effective system-focused actions; however, this has not been evaluated. METHODS: Retrospective mixed methods evaluation of learning teams compared with RCA. Twenty-two learning team investigations compared with 22 RCA investigations, with quantitative assessment of the number of system-focused and person-focused actions generated. Assignment of the two different methods to incidents was not random, with learning teams being selected for cases, which were initially judged to be process-focused problems. Semistructured interviews were conducted with four learning team facilitators with thematic analysis to identify causes for outcome variations. RESULTS: Learning team investigations yielded a median of 7.5 actions compared with 3.5 actions for RCA: 57% of learning team actions were system focused versus 30% for RCA. We identified variations in personnel involved, culture of the investigation, and differences in the investigative approaches as potential drivers for these differences. CONCLUSIONS: We observed that learning team investigations that targeted process-focused problems generated more actions and a higher number of system-focused actions. There is a difference in culture created during learning team investigations. Although learning teams are not suitable for all investigations, they represent a readily reproducible and valuable addition to the investigative toolkit.

Original publication




Journal article


J Patient Saf

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