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

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dc.contributor.author Iedema, Roderick en_US
dc.contributor.author Jorm, Christine en_US
dc.contributor.author Braithwaite, Jeffrey en_US
dc.contributor.author Travaglia, Jo en_US
dc.contributor.author Lum, Martin Elvis en_US
dc.contributor.editor en_US
dc.date.accessioned 2010-05-28T09:56:11Z
dc.date.available 2010-05-28T09:56:11Z
dc.date.issued 2006 en_US
dc.identifier 2006004434 en_US
dc.identifier.citation Iedema Roderick et al. 2006, 'A Root Cause Analysis of clinical error: Confronting the disjunction between formal rules and situated practice.', Elsevier Ltd, vol. 63, no. 5, pp. 1201-1212. en_US
dc.identifier.issn 0277-9536 en_US
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 organizational?managerial 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. en_US
dc.language en_US
dc.publisher Elsevier Ltd en_US
dc.relation.isbasedon http://dx.doi.org/10.1016/j.socscimed.2006.03.035 en_US
dc.title A Root Cause Analysis of clinical error: Confronting the disjunction between formal rules and situated practice. en_US
dc.parent Social Science and Medicine en_US
dc.journal.volume 63 en_US
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 200100 en_US
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


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