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Root-cause analysis: swatting at mosquitoes versus draining the swamp
  1. Patricia Trbovich1,2,
  2. Kaveh G Shojania1,3,4
  1. 1Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  2. 2North York General Hospital, Toronto, Ontario, Canada
  3. 3Department of Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
  4. 4University of Toronto Centre for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
  1. Correspondence to Dr Patricia Trbovich, 155 College suite 425, Toronto, ON, Canada M5T 3M6; patricia.trbovich{at}utoronto.ca

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Many healthcare systems recommend root-cause analysis (RCA) as a key method for investigating critical incidents and developing recommendations for preventing future events. In practice, however, RCAs vary widely in terms of their conduct and the utility of the recommendations they produce.1 ,2 RCAs often fail to explore deep system problems that contributed to safety events3 due to the limited methods used, constrained time and meagre financial/human resources to conduct RCAs.4 Furthermore, healthcare organisations often lack the mandate and authority required to develop and implement sophisticated and effective corrective actions.4 Consequently, corrective actions primarily aim at changing human behaviour rather than system-based changes.5 ,6

In this issue of BMJ Quality and Safety, Kellogg et al7 confirm these concerns about RCAs. Reviewing 302 RCAs conducted over an 8-year period at a US academic medical centre, the authors report the most common solution types as training, process change and policy reinforcement. Serious events (eg, retained surgical sponges) recurred repeatedly despite conducting RCAs. These findings highlight the long overdue need to enhance the effectiveness of RCAs.

Swatting mosquitoes versus draining the swamp

James Reason (of the Swiss Cheese Model8) once characterised the goal of error investigations as draining the swamp not swatting mosquitoes.8 Critical incidents arise from the interplay between active failures (eg, not double checking for allergies before administering a medication) and latent conditions9 (eg, workload for the nurse and reliance on human memory for a critical safeguard when electronic systems with built-in reminders exist). Returning to Reason's analogy, we do not want to spend our time and expend our resources swatting at the mosquitoes of ‘not double checking’. Rather, we want to drain the swamp of the many latent conditions that make not double checking more likely to occur. Too often, RCA teams focus on the …

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