Policy and practice in the use of root cause analysis to investigate clinical adverse events : mind the gap
Nicolini, Davide, Waring, Justin and Mengis, Jeanne. (2011) Policy and practice in the use of root cause analysis to investigate clinical adverse events : mind the gap. Social Science & Medicine, Vol.73 (No.2). pp. 217-225. ISSN 0277-9536
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Official URL: http://dx.doi.org/10.1016/j.socscimed.2011.05.010
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.
|Item Type:||Journal Article|
|Subjects:||R Medicine > RA Public aspects of medicine|
|Divisions:||Faculty of Social Sciences > Warwick Business School|
|Library of Congress Subject Headings (LCSH):||Patients -- Safety measures, Medical care -- Great Britain, Organizational learning|
|Journal or Publication Title:||Social Science & Medicine|
|Official Date:||July 2011|
|Page Range:||pp. 217-225|
|Access rights to Published version:||Restricted or Subscription Access|
|Funder:||Warwick Innovative Manufacturing Research Centre (IMRC), Engineering and Physical Sciences Research Council (EPSRC)|
Andersen, B., & Fagerhaug, T. (2000). Root Cause Analysis: Simplified Tools and Techniques. Milwaukee: ASQ Quality Press.
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