The problem with root cause analysis
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,...
| Main Authors: | , , , |
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| Format: | Article |
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BMJ Publishing Group
2016
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| Online Access: | https://eprints.nottingham.ac.uk/37589/ |
| _version_ | 1848795492054466560 |
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| author | Peerally, Mohammas Farhad Carr, Susan Waring, Justin Dixon-Woods, Mary |
| author_facet | Peerally, Mohammas Farhad Carr, Susan Waring, Justin Dixon-Woods, Mary |
| author_sort | Peerally, Mohammas Farhad |
| building | Nottingham Research Data Repository |
| collection | Online Access |
| description | 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. |
| first_indexed | 2025-11-14T19:32:57Z |
| format | Article |
| id | nottingham-37589 |
| institution | University of Nottingham Malaysia Campus |
| institution_category | Local University |
| last_indexed | 2025-11-14T19:32:57Z |
| publishDate | 2016 |
| publisher | BMJ Publishing Group |
| recordtype | eprints |
| repository_type | Digital Repository |
| spelling | nottingham-375892020-05-04T17:55:31Z https://eprints.nottingham.ac.uk/37589/ The problem with root cause analysis Peerally, Mohammas Farhad Carr, Susan Waring, Justin Dixon-Woods, Mary 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. BMJ Publishing Group 2016-06-23 Article PeerReviewed Peerally, Mohammas Farhad, Carr, Susan, Waring, Justin and Dixon-Woods, Mary (2016) The problem with root cause analysis. BMJ Quality & Safety . ISSN 2044-5423 http://qualitysafety.bmj.com/content/early/2016/06/23/bmjqs-2016-005511.full doi:10.1136/bmjqs-2016-005511 doi:10.1136/bmjqs-2016-005511 |
| spellingShingle | Peerally, Mohammas Farhad Carr, Susan Waring, Justin Dixon-Woods, Mary The problem with root cause analysis |
| title | The problem with root cause analysis |
| title_full | The problem with root cause analysis |
| title_fullStr | The problem with root cause analysis |
| title_full_unstemmed | The problem with root cause analysis |
| title_short | The problem with root cause analysis |
| title_sort | problem with root cause analysis |
| url | https://eprints.nottingham.ac.uk/37589/ https://eprints.nottingham.ac.uk/37589/ https://eprints.nottingham.ac.uk/37589/ |