Kellogg et al on the problems with the learning created from root cause analysis
I read Kathryn Kellogg and colleagues' paper on Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
In the paper the authors describe their findings of the analysis of solutions generated from RCAs at one hospital over an 8-year period. They argue that the most common solutions proposed by the RCA teams are also the most ineffective ones - training, policy reinformcement and disciplining. They provide nice examples (awful in terms of the learning generated) from the RCA reports about how investigation teams are stuck in a work-as-imagined frame of mind believing that their protocols are working effectively, but human errors undermine them.
It is precisely this failure to critically reflect on their assumptions that hinders much progress in patient safety (no double-loop learning). Investigators of safety incidents should study work-as-done, trying to understand the mismatches between protocols and actual practice.
Then, of course, the next step is to abandon the belief that learning needs to focus on what went wrong, and start appreciating the learning that could be harnessed by looking at how people make things work on a daily basis - Safety-II in action.
KELLOGG, K. M., HETTINGER, Z., SHAH, M., WEARS, R. L., SELLERS, C. R., SQUIRES, M. & FAIRBANKS, R. J. 2017. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Quality & Safety, 26, 381-387.