title: Adverse events: root causes and latent factors.
abstract: This article describes the process of root cause analysis (RCA), the theories of error that underlie the concept of systemic or latent factors that allow errors to occur or to be propagated without correction; the difference between the process in health care and those found in high-reliability organizations; and suggests some ways to augment the standard health care RCA into a more robust and helpful process.
authors.affiliation: Department of Surgery, University of South Florida, FL, USA. rkarl@health.usf.edu
authors.forename: Richard
authors.initials: R
authors.lastname: Karl
authors.forename: Mary Catherine
authors.initials: MC
authors.lastname: Karl
mesh_terms: D000060:Accidents, Aviation; D005547:Foreign Bodies / Q000601:surgery; D006801:Humans; D019300:Medical Errors / Q000009:adverse effects* / Q000331:legislation & jurisprudence; D060891:Root Cause Analysis; D013514:Surgical Procedures, Operative / Q000401:mortality*; D015503:Surgical Sponges; D014947:Wounds and Injuries / Q000209:etiology*