Summary
Root cause analysis (RCA) is a widely used method deployed following adverse events in health care. Using a range of information-gathering and analytical tools (such as interviews, the "five whys" technique, fishbone diagrams, change analysis, and others), RCA seeks to understand what happened and why and to identify how to prevent future incidents.
In this PSNet Case and Commentary, Mohammad Farhad Peerally and Mary Dixon-Woods discuss a case where a hospital planned to perform a root cause analysis (RCA) to investigate an adverse event which resulted in an individual blamed and no interventions to prevent similar errors or address systems issues were ever implemented.
Root cause analysis gone wrong (May 2018)
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
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