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Learning from other industries
Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant
  1. J S Carroll1,
  2. J W Rudolph2,
  3. S Hatakenaka1
  1. 1MIT Sloan School of Management, Cambridge, MA 02139, USA
  2. 2Boston College Carroll School of Management, Boston, USA
  1. Correspondence to:
 Dr J S Carroll, MIT Sloan School of Management, 50 Memorial Drive, Cambridge, MA 02139, USA;
 jcarroll{at}mit.edu

Abstract

Root cause analysis was introduced to a chemical plant as a way of enhancing performance and safety, exemplified by the investigation of an explosion. The cultural legacy of the root cause learning intervention was embodied in managers' increased openness to new ideas, individuals' questioning attitude and disciplined thinking, and a root cause analysis process that provided continual opportunities to learn and improve. Lessons for health care are discussed, taking account of differences between the chemical and healthcare industries.

  • root cause analysis
  • safety culture
  • quality improvement

https://doi.org/10.1136/qhc.11.3.266

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    Footnotes

    • ↵* At this plant “root cause” was used as an adjective, never as a noun. They emphasize that there is no single root cause, only an analysis process to learn more about probable causes.

    • ↵* Unlike most companies, investigation of causes is separate from specific recommendations. Managers decide on actions, sometimes with the help of a solution development team.

    • ↵* *While openness was key to the reporting process, written reports were kept brief due to legal and regulatory vulnerability.