Nicolini, Davide, Waring, Justin and Mengis, Jeanne. (2011) The challenges of undertaking root cause analysis in health care: a qualitative study. Journal of Health Services Research & Policy, Volume 16 (Supplement 1). pp. 34-41. ISSN 1355-8196

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Abstract

Objectives: Root cause analysis (RCA) is a framework for structured investigations of safety incidents. Our aim was to identify the barriers to successful learning in health care and to make recommendations for service development.
Methods: A qualitative study that 'tracked' the investigation procedures and practices of ten patient safety incidents in two National Health Service (NHS) hospitals. Non-participant observations of the complete investigation process in various managerial and administrative settings, together with semi-structured qualitative interviews with those involved in the process, and following the completion of the final report.
Results: There are several challenges to undertaking root cause analysis in health care. These are associated with forming and leading the investigation team; gathering and analysing supporting evidence; and formulating and implementing service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.
Conclusions: Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management. Journal of Health Services Research & Policy Vol 16 Suppl 1, 2011: 34-41 (C) The Royal Society of Medicine Press Ltd 2011

Item Type:	Journal Article
Subjects:	R Medicine > R Medicine (General)
Divisions:	Faculty of Social Sciences > Warwick Business School > Innovation, Knowledge & Organisational Networks Research Unit Faculty of Social Sciences > Warwick Business School > Industrial Relations & Organisational Behaviour Faculty of Social Sciences > Warwick Business School
Library of Congress Subject Headings (LCSH):	Root cause analysis, Qualitative research, Medical care -- Evaluation -- Case studies
Journal or Publication Title:	Journal of Health Services Research & Policy
Publisher:	Royal Society of Medicine Press Ltd.
ISSN:	1355-8196
Official Date:	2011
Dates:	Date Event 2011 Published
Volume:	Volume 16
Number:	Supplement 1
Page Range:	pp. 34-41
Identification Number:	10.1258/jhsrp.2010.010092
Status:	Peer Reviewed
Publication Status:	Published
URI:	http://wrap.warwick.ac.uk/id/eprint/41547

Data sourced from Thomson Reuters' Web of Knowledge

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