The problem with root cause analysis

Peerally, Mohammas Farhad; Carr, Susan; Waring, Justin; Dixon-Woods, Mary

Abstract

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 science (4,5) 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-realised (7) and the phenomenon of organisational forgetting (9) remains widespread (Box 1). Here, we identify eight challenges facing the utilisation of RCA in healthcare and offer some proposals on how to improve learning from incidents.

Citation

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (in press). The problem with root cause analysis. BMJ Quality and Safety, https://doi.org/10.1136/bmjqs-2016-005511

• Journal Article Type: Article
• Acceptance Date: May 20, 2016
• Online Publication Date: Jun 23, 2016
• Deposit Date: Oct 17, 2016
• Publicly Available Date: Oct 17, 2016
• Journal: BMJ Quality & Safety
• Print ISSN: 2044-5415
• Electronic ISSN: 2044-5423
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• DOI: https://doi.org/10.1136/bmjqs-2016-005511
• Public URL: https://nottingham-repository.worktribe.com/output/793828
• Publisher URL: http://qualitysafety.bmj.com/content/early/2016/06/23/bmjqs-2016-005511.full