IDEAS home Printed from https://ideas.repec.org/a/eee/socmed/v63y2006i5p1201-1212.html
   My bibliography  Save this article

A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity

Author

Listed:
  • Iedema, Roderick Aren Michael
  • Jorm, Christine
  • Braithwaite, Jeffrey
  • Travaglia, Jo
  • Lum, Martin

Abstract

This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into 'root causes', and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizational-managerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in 'systems improvements' assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care.

Suggested Citation

  • Iedema, Roderick Aren Michael & Jorm, Christine & Braithwaite, Jeffrey & Travaglia, Jo & Lum, Martin, 2006. "A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity," Social Science & Medicine, Elsevier, vol. 63(5), pages 1201-1212, September.
  • Handle: RePEc:eee:socmed:v:63:y:2006:i:5:p:1201-1212
    as

    Download full text from publisher

    File URL: http://www.sciencedirect.com/science/article/pii/S0277-9536(06)00178-X
    Download Restriction: Full text for ScienceDirect subscribers only
    ---><---

    As the access to this document is restricted, you may want to search for a different version of it.

    References listed on IDEAS

    as
    1. David L. Sackett & William M. C. Rosenberg, 1995. "On the need for evidence‐based medicine," Health Economics, John Wiley & Sons, Ltd., vol. 4(4), pages 249-254, July.
    2. Iedema, Roderick Aren Michael & Jorm, Christine & Long, Debbi & Braithwaite, Jeffrey & Travaglia, Jo & Westbrook, Mary, 2006. "Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error," Social Science & Medicine, Elsevier, vol. 62(7), pages 1605-1615, April.
    Full references (including those not matched with items on IDEAS)

    Citations

    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.
    as


    Cited by:

    1. Fischer, Michael Daniel & Ferlie, Ewan, 2013. "Resisting hybridisation between modes of clinical risk management: Contradiction, contest, and the production of intractable conflict," Accounting, Organizations and Society, Elsevier, vol. 38(1), pages 30-49.
    2. Gavan Lintern & Peter N. Kugler, 2017. "Sociotechnical System Safety: Hierarchical Control versus Mindfulness," Systems Engineering, John Wiley & Sons, vol. 20(4), pages 307-317, July.
    3. Nicolini, Davide & Waring, Justin & Mengis, Jeanne, 2011. "Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap," Social Science & Medicine, Elsevier, vol. 73(2), pages 217-225, July.
    4. Alberto Sardi & Enrico Sorano & Letizia Agostini & Anna Guerrieri & Mirella Angaramo & Franco Ripa, 2020. "L?analisi a priori del rischio sanitario in Regione Piemonte: applicazione del metodo Cartorisk sull?area materno-infantile," MECOSAN, FrancoAngeli Editore, vol. 2020(114), pages 67-88.

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Ahmed Al-Imam & Ban A. AbdulMajeed, 2017. "Novel Psychoactive Substances: Systematic Review and Evidence-Based Analysis of Literature," Global Journal of Health Science, Canadian Center of Science and Education, vol. 9(11), pages 1-1, November.
    2. Mathieu Ouimet & Nabil Amara & Réjean Landry & John Lavis, 2007. "Direct interactions medical school faculty members have with professionals and managers working in public and private sector organizations: A cross-sectional study," Scientometrics, Springer;Akadémiai Kiadó, vol. 72(2), pages 307-323, August.
    3. Bradley, Eleanor & Hynam, Brian & Nolan, Peter, 2007. "Nurse prescribing: Reflections on safety in practice," Social Science & Medicine, Elsevier, vol. 65(3), pages 599-609, August.
    4. Joanna Holub-Iwan, 2021. "Management Information Systems of Public Health Behaviors based on Evidence in Medicine and Health Management," European Research Studies Journal, European Research Studies Journal, vol. 0(Special 1), pages 623-643.
    5. Zuiderent-Jerak, Teun & Strating, Mathilde & Nieboer, Anna & Bal, Roland, 2009. "Sociological refigurations of patient safety; ontologies of improvement and 'acting with' quality collaboratives in healthcare," Social Science & Medicine, Elsevier, vol. 69(12), pages 1713-1721, December.
    6. Nicolini, Davide & Waring, Justin & Mengis, Jeanne, 2011. "Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap," Social Science & Medicine, Elsevier, vol. 73(2), pages 217-225, July.
    7. Dreesens, Dunja & Kremer, Leontien & van der Weijden, Trudy, 2019. "The Dutch chaos case: A scoping review of knowledge and decision support tools available to clinicians in the Netherlands," Health Policy, Elsevier, vol. 123(12), pages 1288-1297.
    8. Stephen Birch, 1997. "As a matter of fact: evidence‐based decision‐making unplugged," Health Economics, John Wiley & Sons, Ltd., vol. 6(6), pages 547-559, November.
    9. Goldenberg, Maya J., 2006. "On evidence and evidence-based medicine: Lessons from the philosophy of science," Social Science & Medicine, Elsevier, vol. 62(11), pages 2621-2632, June.
    10. Josje Kok & Ian Leistikow & Roland Bal, 2019. "Pedagogy of regulation: Strategies and instruments to supervise learning from adverse events," Regulation & Governance, John Wiley & Sons, vol. 13(4), pages 470-487, December.
    11. Matthew J Leach & Anne Hofmeyer & Amanda Bobridge, 2016. "The impact of research education on student nurse attitude, skill and uptake of evidence‐based practice: a descriptive longitudinal survey," Journal of Clinical Nursing, John Wiley & Sons, vol. 25(1-2), pages 194-203, January.
    12. Benet Reid, 2016. "Literary Ethnography of Evidence-Based Healthcare: Accessing the Emotions of Rational-Technical Discourse," Sociological Research Online, , vol. 21(4), pages 95-106, November.
    13. Roopa Raman & Anandhi Bharadwaj, 2012. "Power Differentials and Performative Deviation Paths in Practice Transfer: The Case of Evidence-Based Medicine," Organization Science, INFORMS, vol. 23(6), pages 1593-1621, December.
    14. Mia Crampin, 1996. "Letters to the editors," Health Economics, John Wiley & Sons, Ltd., vol. 5(3), pages 271-271, May.
    15. Phillippi, Stephen & Beiter, Kaylin & Thomas, Casey & Vos, Saskia, 2020. "Identifying gaps and using evidence-based practices to serve the behavioral health treatment needs of medicaid-insured children," Children and Youth Services Review, Elsevier, vol. 115(C).
    16. Alan Maynard, 2012. "The powers and pitfalls of payment for performance," Health Economics, John Wiley & Sons, Ltd., vol. 21(1), pages 3-12, January.

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:socmed:v:63:y:2006:i:5:p:1201-1212. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu (email available below). General contact details of provider: http://www.elsevier.com/wps/find/journaldescription.cws_home/315/description#description .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.