The problem with root cause analysis

Cochrane Qualitative and Implementation Methods Group guidance series—paper 2: methods for question formulation, searching, and protocol development for qualitative evidence synthesis

“…Reviews of theory provide a useful starting point for problem framing, as they can be used to map the various explanations of relationships between individual circumstances, wellbeing and health [11]. Logic models can be used to articulate relationships between cause and effect using root cause analysis [12][13][14][15][16].…”

“…• Retroactively or proactively assess risk, identifying factors that compromise patient safety [14] • Map flows and blockages in services at a systems level [15] • Help policymakers do actionable cause analysis, in order to prioritise the problems that are most feasible to address [16] M A N U S C R I P T Box 2 -Approaches to involving stakeholders in reviews 1) Before-After involvement: Stakeholders are included during the problem framing stage, and then comment on the results of the review towards the end of the process. [19] 2) Iterative involvement: Stakeholders are consulted at agreed milestones during the review which may entail a number of milestones with the aim of promoting higher levels of engagement, ownership and active dissemination of findings [20] 3) Synchronous involvement: is 'real time' two-way involvement representing an active exchange and comparison of review findings with practitioner and service user experience.,where involvement is used to collectively interpret and co-produce the review.…”

Análisis Causa-Raíz Sobre Evento Adverso Producido en la Clínica Odontológica Docente Asistencial, Facultad de Odontología, Universidad de La Frontera, Chile

“…Aunque se han señalado limitaciones en los alcances de un ACR (susceptibilidad a politización de su gestión, tendencia a producir controles insuficientes de riesgo, malfuncionamiento de su retroalimentación, confusión sobre culpa y responsabilidad, etc.) (Peerally et al, 2016), y en odontología específicamente existen muy escasas referencias a su implementación técnica (Peleg et al, 2010;PereaPérez et al, 2011b), coincidimos con la literatura en la necesidad de investigación y reportes para comprender a cabalidad cuáles son las claves para llevar adelante de manera correcta una atención sanitaria odontológica centrada en el paciente que asegure calidad, seguridad y eficiencia (Mills et al, 2013;Ramoni et al, 2012;2014).…”

On safety ontology: a cross-section analysis of incident investigations in a public healthcare system

“…Both legislation and the HaSCI emphasise the responsibility of the healthcare provider organisation (HPO) to learn from adverse events, as well as sharing this learning with others. However, contemporary safety science research has shown that such learning and sharing can be difficult for organisations to apply in practice [9,10] and that organisational forgetting is a common phenomenon [11,12].…”