A Root Cause Analysis of clinical error: Confronting the disjunction between formal rules and situated practice.

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dc.contributor.author Iedema, RA
dc.contributor.author Jorm, C
dc.contributor.author Braithwaite, J
dc.contributor.author Travaglia, J
dc.contributor.author Lum, ME
dc.date.accessioned 2010-05-28T09:56:11Z
dc.date.issued 2006-01
dc.identifier.citation Social Science and Medicine, 2006, 63 (5), pp. 1201 - 1212
dc.identifier.issn 0277-9536
dc.identifier.other C1UNSUBMIT en_US
dc.identifier.uri http://hdl.handle.net/10453/10419
dc.description.abstract This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into `root causes, and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizationalmanagerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in `systems improvements assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care.
dc.publisher Elsevier Ltd
dc.relation.isbasedon 10.1016/j.socscimed.2006.03.035
dc.subject Root cause analysis, Hospital clinicians, Clinical error, Organizational learning, Australia, Public Health
dc.subject Root cause analysis; Hospital clinicians; Clinical error; Organizational learning; Australia; Public Health
dc.title A Root Cause Analysis of clinical error: Confronting the disjunction between formal rules and situated practice.
dc.type Journal Article
dc.parent Social Science and Medicine
dc.journal.volume 5
dc.journal.volume 63
dc.journal.number 5 en_US
dc.publocation Oxford, UK en_US
dc.identifier.startpage 1201 en_US
dc.identifier.endpage 1212 en_US
dc.cauo.name FASS.Faculty of Arts and Social Sciences en_US
dc.conference Verified OK en_US
dc.for 2001 Communication and Media Studies
dc.personcode 100638 en_US
dc.personcode 102618 en_US
dc.personcode 0000024489 en_US
dc.personcode 0000028330 en_US
dc.personcode 10634160 en_US
dc.percentage 100 en_US
dc.classification.name Communication and Media Studies en_US
dc.classification.type FOR-08 en_US
dc.edition en_US
dc.custom en_US
dc.date.activity en_US
dc.location.activity en_US
dc.description.keywords Root cause analysis; Hospital clinicians; Clinical error; Organizational learning; Australia en_US
dc.description.keywords Root cause analysis
dc.description.keywords Hospital clinicians
dc.description.keywords Clinical error
dc.description.keywords Organizational learning
dc.description.keywords Australia
pubs.embargo.period Not known
pubs.organisational-group /University of Technology Sydney
pubs.organisational-group /University of Technology Sydney/Faculty of Arts and Social Sciences
pubs.organisational-group /University of Technology Sydney/Faculty of Health
pubs.organisational-group /University of Technology Sydney/Strength - Research in Learning and Change


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