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Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents,1–3 is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events,1 RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science4 ,5 that are used to establish how and why an incident occurred in an attempt to identify how it, and similar problems, might be prevented from happening again.6 In this article, we propose that RCA does have potential value in healthcare, but it has been widely applied without sufficient attention paid to what makes it work in its contexts of origin, and without adequate customisation for the specifics of healthcare.7 ,8 As a result, its potential has remained under-realised7 and the phenomenon of organisational forgetting9 remains widespread (box 1). Here, we identify eight challenges facing the usage of RCA in healthcare and offer some proposals on how to improve learning from incidents.
Lessons not learnt
This example provides a summary of a real case that occurred in a hospital and the failure to learn from the incident in spite of a root cause analysis.
In a large acute hospital, a patient underwent a routine cataract surgery—an operation with a minimal risk profile—led by an experienced ophthalmologist. The wrong lens was inserted during the operation. The error was promptly recognised postoperatively; the patient was returned to the operating room and the procedure was safely redone.
A subsequent root cause analysis …
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Contributors MFP wrote the first draft of the manuscript, which was subsequently revised critically and edited by SC, JW and MD-W. MD-W edited the final version of the manuscript. All authors approved the final manuscript version being submitted for publication.
Funding Wellcome Trust Senior Investigator Award (Mary Dixon-Woods (WT097899)) and Health Foundation (Improvement Science Doctoral Awards).
Competing interests MD-W is the Deputy Editor-in-Chief of BMJ Quality and Safety.
Provenance and peer review Not commissioned; externally peer reviewed.
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