IKON, Warwick Business School, University of Warwick, Gibbet Hill Road, Coventry, UK.
J Health Serv Res Policy. 2011 Apr;16 Suppl 1:34-41. doi: 10.1258/jhsrp.2010.010092.
Root cause analysis (RCA) is a framework for structured investigations of safety incidents. Our aim was to identify the barriers to successful learning in health care and to make recommendations for service development.
A qualitative study that 'tracked' the investigation procedures and practices of ten patient safety incidents in two National Health Service (NHS) hospitals. Non-participant observations of the complete investigation process in various managerial and administrative settings, together with semi-structured qualitative interviews with those involved in the process, and following the completion of the final report.
There are several challenges to undertaking root cause analysis in health care. These are associated with forming and leading the investigation team; gathering and analysing supporting evidence; and formulating and implementing service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.
Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management.
根本原因分析（RCA）是一种针对安全事件进行结构化调查的框架。我们的目的是确定医疗保健领域中成功学习的障碍，并为服务发展提出建议。
这是一项定性研究，“跟踪”了两家英国国家医疗服务体系（NHS）医院的十起患者安全事件的调查程序和做法。在各种管理和行政环境中对整个调查过程进行非参与式观察，以及对参与该过程的人员进行半结构化定性访谈，并在完成最终报告后进行。
在医疗保健中进行根本原因分析存在一些挑战。这些挑战与组建和领导调查团队、收集和分析支持证据以及制定和实施服务改进有关。进行根本原因分析仍然是一项复杂的非线性任务，需要平衡多种关注和期望。支持增强的事件调查需要将触发可持续服务改进的工具性目标放在首位，而不是将调查本身作为目的。
卫生服务领导者需要对根本原因分析及其实施人员表示公开支持；增强员工在学习活动和新分析工具中的参与度；并发展变革管理能力。
