A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity

Iedema, Rick; Jorm, Christine; Braithwaite, Jeffrey; Travaglia, Joanne; Lum, Martin

doi:10.1016/j.socscimed.2006.03.035

Cited by 53 publications

(52 citation statements)

References 22 publications

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“…2006a;2006b). In our study, for example, we found that RCA constituted a visible historical improvement as "in the old time every department did it its own way and what happened depended very much on the whims of the clinical lead".…”

Section: Root Cause Analysis In Healthcarementioning

confidence: 99%

“…These comments resonate with findings by Carroll et al (2002) who suggest that RCA constitutes a tool for promoting a shift in culture towards more trust and openness as clinicians from a variety of backgrounds participate in the processes of learning. Similarly, Iedema et al (2006a;2006b) note that RCA affords healthcare practitioners a space for new (and challenging) conversation and reflection.…”

Section: Root Cause Analysis In Healthcarementioning

confidence: 99%

“…The result is that investigations themselves often become part of "the game" they are supposed to portray. For example, RCA investigations are perceived (and conducted) as a form of imposed scrutiny of the work practices (Iedema et al, 2006a), where staff engage in various protective manoeuvres to maintain control over their organisational and disciplinary jurisdictions, and to defend their reputation. These manoeuvres range from not providing requested information, to not participating in meetings.…”

Section: Making Change Happen After the Investigationmentioning

confidence: 99%

“…While RCA is formally endorsed by policy makers in USA, UK, Australia, and Denmark (Øvretveit, 2005) and is in the process of being adopted by other countries, we have only a partial understanding of the challenges of using this approach, despite research suggesting it is not without problems (Wallace, 2006;Braithwaite et al, 2006;Iedema et al 2006a;2006b, Wu et al, 2008. Building on an extensive 12-months ethnographic study within two large acute hospitals in the UK National Health Service (NHS), we examine how the investigation of clinical incidents is conducted in practice.…”

Section: Introductionmentioning

confidence: 99%

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Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Nicolini

Waring

Mengis

2011

Social Science & Medicine

112

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Publisher statement: NOTICE: this is the author's version of a work that was accepted for publication in Social Science and Medicine. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Social Science and Medicine, 73(2), (2011) POLICY AND PRACTICE IN THE USE OF ROOT CAUSE ANALYSIS TO INVESTIGATE CLINICAL ADVERSE EVENTS: MIND THE GAP AbstractThis paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-months ethnographic study in two large acute NHS hospitals in the UK and documented the process of incident investigation, reporting, and translation of the results into practice. We found that the approach has both strengths and problems. The latter stem, in part, from contradictions between potentially incompatible organizational agendas and social logics that drive the use of this approach. While Root Cause Analysis was originally conceived as an organisational learning technique, it is also used as a governance tool and a way to re-establish organisational legitimacy in the aftermath of incidents. The presence of such diverse and partially contradictory aims creates tensions with the result that efforts are at times diverted from the aim of producing sustainable change and improvement. We suggest that a failure to understand these inner contradictions, together with unreflective policy interventions, may produce counterintuitive negative effects which hamper, instead of further, the cause of patient safety.3

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Section: Root Cause Analysis In Healthcarementioning

confidence: 99%

Section: Root Cause Analysis In Healthcarementioning

confidence: 99%

Section: Making Change Happen After the Investigationmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Nicolini

Waring

Mengis

2011

Social Science & Medicine

112

View full text Add to dashboard Cite

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“…This means a detailed examination of the nature of the intervention 61 and a broad examination of its effects, which may lay in other places than the predetermined area of interest; for example the effect of medical emergency teams on "not for resuscitation orders" 62,63 and palliative care, or the effect of participation in the root cause analysis process on improving organisational communication. 64 When the interventions themselves have a clearly described theoretical framework, meaningful evaluation is more likely. 65 The spread of best practice has proven an elusive goal.…”

Section: Evaluation Of Complex Interventionsmentioning

confidence: 99%

Using research to make health care safer

Jorm¹,

White²

2009

Aust. Health Review

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There is a fine balance that needs to be maintained between research and improvement in safety and quality in health care -when do we need more research and when can we just get on with it? The moral imperative to improve care may have been a distractor, preventing adequate attention to research. Three research areas are proposed as current priorities for patient safety: getting evidence into practice, measurement of safety, and the evaluation of complex interventions. A focus on these areas should ensure that research becomes more central to the process of WHAT PLACE DOES RESEARCH play in safety and quality and when should we just "get on with it"? The discourse of modern government is crisp, if not blunt: the National Health and Hospitals Reform Commission had among its terms of reference the requirement to "reduce inefficiencies generated by cost-shifting, blame-shifting and buck passing". 1 (p. 357) The development of performance indicators continues apace, and the research community is not always seen as essential to the process of making health care safer.The research-policy divide is well documented and has led to the modern development of new specialties such as knowledge transfer or translation, 2 and brokering and exchange. 3 However, policy imperatives mean policy makers are impatient with research timeframes and wary of recommendations that may make compromise difficult. 4 Human interaction has been described as "the engine that drives research into practice", 5 yet the inclusion of clinicians, managers and policy makers (or research users) into research funding programs is rare in Australia and only partial in Canada. 5 In the case of quality and safety, however, there are further problems. Traditional quantitative research methods may be inadequate tools (particularly for areas such as clinical handover and other health care communication), and in addition, the need to improve safety and quality has been associated with a moral imperative which has been held to obviate the need for research and has been associated with denigration of its value. Berwick, in a recent piece advocating safety and quality research, used rhetoric displaying the customary antagonism of safety and quality exponents towards research: "Health care researchers What is known about the topic? It is unsure how much safety and quality has improved over the last two decades. There is a deficiency of high quality research to support the design of safety improvement. What does this paper add?The lack of formal study means that neither clinicians nor policy makers understand the system in which they work sufficiently to reliably get evidence into practice. Inadequate measurement in safety prevents appropriate priority setting. Meaningful evaluations must include the study of failure. The use of a theoretical basis for both intervention and evaluation increases the likelihood of transferable learning. What are the implications for practitioners? Safety and quality advocates are requested to accompany their exhortations for cha...

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Sensemaking and the co‐production of safety: a qualitative study of primary medical care patients

Rhodes¹,

McDonald²,

Campbell³

et al. 2016

The Sociology of Healthcare Safety and Quality

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This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

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A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity

Cited by 53 publications

References 22 publications

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Using research to make health care safer

Sensemaking and the co‐production of safety: a qualitative study of primary medical care patients

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