Patient safety: the causes everyone on the ward can see, together

A review team asks why an incident happened, and one analyst writes the answer. But the causes of a recurring safety problem are spread across the people involved: the nurse on nights, the pharmacist, the registrar, the patient who waited. No single reviewer holds them all.

True Causes lets that whole group do the analysis. Everyone writes causes alone and unnamed, so a junior nurse can say what a consultant would not. Then the group judges, pair by pair, whether one cause significantly influences another, and a link counts only at three quarters of the votes. The deepest causes are the ones everything else traces back to.

Several wards or sites can each run their own room on the same question, and the maps fold into one: the causes found independently in several places stand out from the local ones.