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The problem with root cause analysis
  1. Mohammad Farhad Peerally1,
  2. Susan Carr2,
  3. Justin Waring3,
  4. Mary Dixon-Woods1
  1. 1SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK
  2. 2John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK
  3. 3CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Mohammad Farhad Peerally, SAPPHIRE, Department of Health Sciences, University of Leicester, Centre for Medicine University Road Leicester, LE1 7RH UK; mfp6{at}le.ac.uk

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Introduction

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.

Box 1

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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