title: Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap.
abstract: This paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-month ethnographic study in two large acute NHS hospitals in the U.K. 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.
authors.affiliation: Warwick Business School, The University of Warwick, Coventry CV4 7AL, UK. davide.nicolini@wbs.ac.uk
authors.forename: Davide
authors.initials: D
authors.lastname: Nicolini
authors.forename: Justin
authors.initials: J
authors.lastname: Waring
authors.forename: Jeanne
authors.initials: J
authors.lastname: Mengis
mesh_terms: D000884:Anthropology, Cultural; D006291:Health Policy / Q000331:legislation & jurisprudence*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000331:legislation & jurisprudence* / Q000517:prevention & control; D017146:Models, Organizational; D005791:Patient Care; D018570:Risk Assessment; D012308:Risk Management; D012449:Safety / Q000331:legislation & jurisprudence*; D017751:Safety Management; D013222:State Medicine; D006113:United Kingdom