title: Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant.
abstract: 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.
authors.affiliation: MIT Sloan School of Management, 50 Memorial Drive, Cambridge, MA 02139, USA. jcarroll@mit.edu
authors.forename: J S
authors.initials: JS
authors.lastname: Carroll
authors.forename: J W
authors.initials: JW
authors.lastname: Rudolph
authors.forename: S
authors.initials: S
authors.lastname: Hatakenaka
mesh_terms: D002617:Chemical Industry / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration; D004059:Diffusion of Innovation; D005107:Explosions; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D016272:Occupational Health; D019982:Organizational Case Studies; D015279:Organizational Culture; D017751:Safety Management / Q000379:methods*; D013597:Systems Analysis; D017749:Total Quality Management; D014481:United States