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thumbnail of A Human Factors approach to developing a learning toolkit for the NHS

Author
Tracey A Herlihey, Jane Carthey, Lauren Mosley, Matthew Fogarty
Abstract
Despite huge effort invested in investigating patient safety incidents in the NHS, mounting evidence pointed to a need for a fresh approach. To enable the NHS to move from Root Cause Analysis (RCA) to a more flexible and proportionate approach to learning from safety events, a human factors informed Learning Response Toolkit was developed.