IDEAS home Printed from
MyIDEAS: Log in (now much improved!) to save this article

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Listed author(s):
  • Nicolini, Davide
  • Waring, Justin
  • Mengis, Jeanne
Registered author(s):

    This paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-month ethnographic study in two large acute NHS hospitals in the UK and documented the process of incident investigation, reporting, and translation of the results into practice. We found that the approach has both strengths and problems. The latter stem, in part, from contradictions between potentially incompatible organizational agendas and social logics that drive the use of this approach. While Root Cause Analysis was originally conceived as an organisational learning technique, it is also used as a governance tool and a way to re-establish organisational legitimacy in the aftermath of incidents. The presence of such diverse and partially contradictory aims creates tensions with the result that efforts are at times diverted from the aim of producing sustainable change and improvement. We suggest that a failure to understand these inner contradictions, together with unreflective policy interventions, may produce counterintuitive negative effects which hamper, instead of further, the cause of patient safety.

    If you experience problems downloading a file, check if you have the proper application to view it first. In case of further problems read the IDEAS help page. Note that these files are not on the IDEAS site. Please be patient as the files may be large.

    File URL:
    Download Restriction: Full text for ScienceDirect subscribers only

    As the access to this document is restricted, you may want to look for a different version under "Related research" (further below) or search for a different version of it.

    Article provided by Elsevier in its journal Social Science & Medicine.

    Volume (Year): 73 (2011)
    Issue (Month): 2 (July)
    Pages: 217-225

    in new window

    Handle: RePEc:eee:socmed:v:73:y:2011:i:2:p:217-225
    Contact details of provider: Web page:

    Order Information: Postal:

    References listed on IDEAS
    Please report citation or reference errors to , or , if you are the registered author of the cited work, log in to your RePEc Author Service profile, click on "citations" and make appropriate adjustments.:

    in new window

    1. Waring, Justin J., 2009. "Constructing and re-constructing narratives of patient safety," Social Science & Medicine, Elsevier, vol. 69(12), pages 1722-1731, December.
    2. 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.
    3. Beth Kewell & Matthias Beck, 2008. "NHS Inquiries: A Time Series Analysis," Public Money & Management, Taylor & Francis Journals, vol. 28(6), pages 375-382, December.
    4. John S. Carroll, 1998. "Organizational Learning Activities in High-hazard Industries: The Logics Underlying Self-Analysis," Journal of Management Studies, Wiley Blackwell, vol. 35(6), pages 699-717, November.
    5. Beth Kewell & Matthias Beck, 2008. "NHS Inquiries: A Time Series Analysis," Public Money & Management, Chartered Institute of Public Finance and Accountancy, vol. 28(6), pages 375-382, December.
    6. Vincent, Charles, 2009. "Social scientists and patient safety: Critics or contributors?," Social Science & Medicine, Elsevier, vol. 69(12), pages 1777-1779, December.
    7. 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.
    8. Mesman, Jessica, 2009. "The geography of patient safety: A topical analysis of sterility," Social Science & Medicine, Elsevier, vol. 69(12), pages 1705-1712, December.
    9. Iedema, Rick, 2009. "New approaches to researching patient safety," Social Science & Medicine, Elsevier, vol. 69(12), pages 1701-1704, December.
    Full references (including those not matched with items on IDEAS)

    This item is not listed on Wikipedia, on a reading list or among the top items on IDEAS.

    When requesting a correction, please mention this item's handle: RePEc:eee:socmed:v:73:y:2011:i:2:p:217-225. See general information about how to correct material in RePEc.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (Dana Niculescu)

    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 references are entirely missing, you can add them using this form.

    If the full references list an item that is present in RePEc, but the system did not link 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 profile, as there may be some citations waiting for confirmation.

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

    This information is provided to you by IDEAS at the Research Division of the Federal Reserve Bank of St. Louis using RePEc data.