Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap
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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Volume (Year): 73 (2011)
Issue (Month): 2 (July)
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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.:
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- 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.
- 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.
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