Date of Conferral



Doctor of Education (Ed.D.)




Nancy Walters


Research shows that, when unintentional harm to patients in outpatient and hospital settings occurs, root cause analysis (RCA) investigations should be conducted to identify and implement corrective actions to prevent future patient harm. Executives at a small healthcare consulting company that employs patient safety officers (PSOs) responsible for conducting RCAs were concerned with the low quality of RCA outcomes, prompting this postinvestigation assessment of PSOs' RCA training and experiences. Guided by adult learning theory, the purpose of this study was to assess PSOs' RCA training and investigation experiences by examining self-reported benefits, attitudes, barriers, and time since training, and the relationship between time since training and the number of barriers encountered during RCA investigations. This quantitative study used a preestablished survey with a purposeful sample of 89 PSOs located at 75 military health care facilities in the United States and abroad. Data analysis included descriptive statistics and Kendall's tau-b correlations. Results indicated that PSOs had positive training experiences, valued RCA investigations, varied on the time since RCA training, and encountered barriers conducting RCAs. Kendall's tau-b correlation analysis showed that the time since training was not significantly associated with the frequency of barriers they encountered. Findings suggest that the transfer of technical RCA knowledge was applied during actual RCA investigations regardless of time since training, and barriers contributed to subpar quality RCA outcomes. RCA professional development was designed to enhance nontechnical, soft competency skills as a best practice to overcome encountered barriers and promote social change in the field.