The problem with root cause analysis

Affiliations

¹ SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK.
² John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK.
³ CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK.

Mohammad Farhad Peerally et al. BMJ Qual Saf. 2017 May.

. 2017 May;26(5):417-422.

doi: 10.1136/bmjqs-2016-005511. Epub 2016 Jun 23.

¹ SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK.
² John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK.
³ CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK.

No abstract available

Keywords: Adverse events, epidemiology and detection; Patient safety; Risk management; Root cause analysis.

Conflict of interest statement

Competing interests: MD-W is the Deputy Editor-in-Chief of BMJ Quality and Safety.

1. Bagian JP, Gosbee J, Lee CZ, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Patient Saf 2002;28:531–45. - PubMed
1. Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care 2006;15:393–9. 10.1136/qshc.2005.017525 - DOI - PMC - PubMed
1. NHS England. Serious incident framework. Supporting Learning to Prevent Recurrence. 2015. http://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-fra... (accessed 31 Dec 2015).
1. Reason J. Human error. Cambridge University Press, 1990.
1. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154–7. 10.1136/bmj.316.7138.1154 - DOI - PMC - PubMed