TY - JOUR T1 - Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant JF - Quality and Safety in Health Care JO - Qual Saf Health Care SP - 266 LP - 269 DO - 10.1136/qhc.11.3.266 VL - 11 IS - 3 AU - J S Carroll AU - J W Rudolph AU - S Hatakenaka Y1 - 2002/09/01 UR - http://qualitysafety.bmj.com/content/11/3/266.abstract N2 - 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. ER -