Lifting the lid on root cause analysis: A document analysis

摘要: Abstract Background Root Cause Analysis (RCA) has been applied as a structured analytical technique to investigate patient harm events in Queensland Health since 2005; however, no research conducted on the text of RCAs across clinical services. Methods A document analysis was original RCA reports from 2009, 2010, and 2011. Strict legislative conditions existed de-contextualised comprised data. The function systematic process masked by language decoys that saw relevant cause effect information circumvented or ignored. Thus, latent organisational issues were not sufficiently identified causality disconnected solutions. Active failures dominated due lack systemic analysis. Conclusion does conform dominant theoretic work safety, policy objectives. systems approach is compromised because creative methods inform RCA.