The challenges of undertaking root cause analysis in health care: A qualitative study

Abstract

Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management.

The problem with root cause analysis

“…The task facing the investigation team is far from straightforward: the events underlying an incident have to be reconstructed from many different sources of varying degrees of reliability, usefulness and accessibility, ranging from hospital records, staff interviews and statements, to records of workforce rotas. 15 The information obtained directly from healthcare workers is influenced by their willingness and ability to provide relevant data 16 17 and by nature of the relationships and conversations between investigators and other stakeholders. 18 The involvement of patients and families affected by the incident is wildly variable, with only limited evidence-based guidance on how it can best be done.…”

Safety lessons: shifting paradigms and new directions for patient safety research

“…Similarly, research on the implementation of incident reporting and root cause analysis techniques highlights how professional boundaries and hierarchies can inhibit attempts to engender learning. [29][30][31] Ignoring the particular context of safety intervention, limits its impact in two ways. On the one hand, some argue that health care systems have more complexity than other industries.…”

Why Do Some Parents Refuse Consent for Lumbar Puncture on Their Child? A Qualitative Study

“…We undertook a qualitative analysis of their perspectives, beliefs, and attitudes behind such refusal in an exploratory and hypothesis-generating exercise. [3][4][5][6] The results VOLUME 2 • ISSUE 2 www.hospitalpediatrics.org would allow a detailed understanding of families' experiences, motives, views, feelings, wants, needs, and concerns regarding the giving of consent, directly from their own perspective. The aim is to suggest appropriate solutions and strategies to minimize this refusal.…”