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

Social Science and Medicine

Volumn 73, Issue 2, 2011, Pages 217-225

  Nicolini, Davide ^a   Waring, Justin ^b   Mengis, Jeanne ^a,c  

^a UNIVERSITY OF WARWICK   (United Kingdom)

^b UNIVERSITY OF NOTTINGHAM   (United Kingdom)

^c UNIVERSITY OF LUGANO   (Switzerland)

Author keywords

Incident investigation; Organizational learning; Patient safety; Policy translation; Root cause analysis

Indexed keywords

HEALTH SERVICES; HOSPITAL SECTOR; ORGANIZATIONAL FRAMEWORK; SAFETY; SUSTAINABILITY;

ARTICLE; ETHNOGRAPHIC RESEARCH; HOSPITAL CARE; HOSPITAL POLICY; INCIDENT REPORT; NATIONAL HEALTH SERVICE; ORGANIZATION; ORGANIZATIONAL LEARNING; PATIENT SAFETY; ROOT CAUSE ANALYSIS; THEORY-PRACTICE RELATIONSHIP; UNITED KINGDOM;

ANTHROPOLOGY, CULTURAL; GREAT BRITAIN; HEALTH POLICY; HOSPITALS; HUMANS; MEDICAL ERRORS; MODELS, ORGANIZATIONAL; PATIENT CARE; RISK ASSESSMENT; RISK MANAGEMENT; SAFETY; SAFETY MANAGEMENT; STATE MEDICINE;

UNITED KINGDOM;

EID: 79960208168     PISSN: 02779536     EISSN: 18735347     Source Type: Journal    
DOI: 10.1016/j.socscimed.2011.05.010     Document Type: Article

References (42)

1. Amo M. Root cause analysis. A tool for understanding why accidents occur. Balance 1998, 2(5):12-15.
2. Andersen B., Fagerhaug T. Root cause analysis: Simplified tools and techniques 2000, ASQ Quality Press, Milwaukee.
3. Bagian J.P., Gosbee J., Lee C.Z., Williams L., McKnight S.D., Mannos D.M. The veterans affairs root cause analysis system in action. JACO Journal of Quality Improvement 2002, 28:531-545.
4. Braithwaite J., Westbrook M., Mallock N., Travaglia J., Iedema R. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Quality & Safety in Health Care 2006, 15(6):393.
5. Brown A. Authoritative sensemaking in a public inquiry report. Organization Studies 2004, 25(1):95-112.
6. Carroll J.S. Organizational learning activities in high-hazard industries: the logics underlying self-analysis. Journal of Management Studies 1998, 35:699-717.
7. Carroll J.S., Rudolph J.W., Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Quality & Safety in Health Care 2002, 11:266-269.
8. Doing less harm. Improving the safety and quality of care through reporting, analysing and learning from adverse incidents involving NHS patients 2001, Department of Health, DoH, London.
9. Donaldson L. An organisation with a memory. Clinical Medicine 2000, 2(5):452-457.
10. Downham G., Lingham R. Learning lessons: using inquiries for change. Journal of Mental Health Law 2009, 18:57-69.
11. Engeström Y. Expansive learning at work: toward an activity theoretical reconceptualization. Journal of Education and Work 2001, 14(1):133-156.
12. Heget J.R., et al. Eisenberg patient safety awards. System innovation: veterans health administration national center for patient safety. Joint Commission Journal of Quality Improvement 2002, 28:660-665.
13. Investigatory inquiries 2004, House of Commons Library, Standard Note, SN/PC/2599, 30 November.
14. Iedema R.A. New Approaches to researching patient safety. Social Science & Medicine 2009, 69(12):1701-1704.
15. Iedema R.A., Jorm C., Braithwaite J., et al. A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. Social Science & Medicine 2006, 63:1201-1212.
16. Iedema R.A., Jorm C., Long D., Braithwaite J., Travaglia J., Westbrook M. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Social Science & Medicine 2006, 62:1605-1615.
17. Iedema R., Jorm C., Braithwaite J. Managing the scope and impact of root cause analysis recommendations. Journal of Health Organisation and Management 2008, 22(6):569-585.
18. Kewell B., Beck M. NHS inquiries: a time series analysis. Public Money & Management 2008, 28(6):375-382.
19. Latour B. Science in action 1986, Harvard University Press, Cambridge, Mass.
20. Mesman J. The geography of patient safety: a topical analysis of sterility. Social Science & Medicine 2009, 69(12):1705-1712.
21. Root cause analysis toolkit 2004, NPSA, Available online at, Accessed 27.10.10. http://www.nrls.npsa.nhs.uk/.
22. RCA investigation tools: Guide to investigation report writing 2008, NPSA, Document 0769B V1.
23. Øvretveit J. Effectiveness of interventions to improve patient safety. A review of research and guidance 2005, Karolinska Institute, Stockholm.
24. Power M. Organized Uncertainty: Designing a world of risk management 2007, University Press, Oxford.
25. Reason J. Human error 1990, Cambridge University Press, New York.
26. Reason P., Bradbury H. Handbook of action research 2007, Sage, London.
27. Spradley J.P. The ethnographic interview 1979, Thomson Learning, New York.
28. Tamuz M., Franchois K.E., Thomas E.J. What's past is prologue: organizational learning from a serious patient injury. Safety Science 2011, 49(1):75-82.
29. Vince R. Power and emotion in organizational learning. Human Relations 2001, 54(10):1325-1351.
30. Vincent C.A. Social scientists and patient safety: critics or contributors?. Social Science & Medicine 2009, 69(12):1777-1779.
31. Vincent C.A., Taylor-Adams S., Stanhope N. A framework for the analysis of risk and safety in medicine. British Medical Journal 1998, 316:1154-1157.
32. Vincent C., Stanhope N., Crowley Murphy M. Reasons for not reporting adverse incidents: an empirical study. Journal of Evaluation in Clinical Practice 1999, 5(1):13-21.
33. Wakefield A., Carlisle C., Hall A., Attree M. Patient safety investigations: the need for interprofessional learning. Learning in Health and Social Care 2008, 8(1):22-32.
34. Wald H., Shojania K.G. Root cause analysis. Making health care safer: A critical analysis of patient safety practices 2001, Evidence Report/Technology Assessment No. 43, AHRQ Publications. K.G. Shojania (Ed.).
35. Wallace L.M. From root cause analysis to safer systems: international comparisons of nationally sponsored healthcare staff training programmes. Quality & Safety in Health Care 2006, 15(6):400-402.
36. Walshe K. Inquiries: Learning from failures in the NHS? 2003, The Nuffield Trust, London.
37. Waring J. Adaptive regulation or governmentality: patient safety and the changing regulation of medicine. Sociology of Health and Illness 2007, 29:163-179.
38. Waring J. Constructing and re-constructing narratives of patient safety. Social Science & Medicine 2009, 69(12):1722-1731.
39. Weick K.E., Westley F. Organizational learning: affirming an oxymoron. Handbook of organization studies 1996, 440-458. Sage, London. S.R. Clegg, C. Hardy, W. Nord (Eds.).
40. Woloshynowych M., Rogers S., Taylor-Adams S., Vincent C. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment 2005, 9(19).
41. Wu A.W., Lipshutz A.K., Pronovost P.M. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008, 299:685-687.
42. Zuiderent-Jerak T., Strating M., Nieboer A., Bal R. Sociological refigurations of patient safety. Social Science & Medicine 2009, 69:1713-1721.