title: Making sense of root cause analysis investigations of surgery-related adverse events.
abstract: This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.
authors.affiliation: University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia. bryce.cassin@gmail.com
authors.forename: Bryce R
authors.initials: BR
authors.lastname: Cassin
authors.forename: Paul R
authors.initials: PR
authors.lastname: Barach
mesh_terms: D006801:Humans; D061214:Patient Safety; D060891:Root Cause Analysis; D013514:Surgical Procedures, Operative / Q000009:adverse effects*