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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.

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    File URL: http://www.sciencedirect.com/science/article/pii/S0277953611002851
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    Article provided by Elsevier in its journal Social Science & Medicine.

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

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    Handle: RePEc:eee:socmed:v:73:y:2011:i:2:p:217-225
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    1. Iedema, Rick, 2009. "New approaches to researching patient safety," Social Science & Medicine, Elsevier, vol. 69(12), pages 1701-1704, December.
    2. 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.
    3. 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.
    4. Mesman, Jessica, 2009. "The geography of patient safety: A topical analysis of sterility," Social Science & Medicine, Elsevier, vol. 69(12), pages 1705-1712, December.
    5. Waring, Justin J., 2009. "Constructing and re-constructing narratives of patient safety," Social Science & Medicine, Elsevier, vol. 69(12), pages 1722-1731, December.
    6. 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.
    7. Beth Kewell & Matthias Beck, 2008. "NHS Inquiries: A Time Series Analysis," Public Money & Management, Taylor & Francis Journals, vol. 28(6), pages 375-382, December.
    8. 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.
    9. Vincent, Charles, 2009. "Social scientists and patient safety: Critics or contributors?," Social Science & Medicine, Elsevier, vol. 69(12), pages 1777-1779, December.
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