Warwick Business School, The University of Warwick, Coventry CV4 7AL, UK.
Soc Sci Med. 2011 Jul;73(2):217-25. doi: 10.1016/j.socscimed.2011.05.010. Epub 2011 May 27.
This paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-month ethnographic study in two large acute NHS hospitals in the U.K. and documented the process of incident investigation, reporting, and translation of the results into practice. We found that the approach has both strengths and problems. The latter stem, in part, from contradictions between potentially incompatible organizational agendas and social logics that drive the use of this approach. While Root Cause Analysis was originally conceived as an organisational learning technique, it is also used as a governance tool and a way to re-establish organisational legitimacy in the aftermath of incidents. The presence of such diverse and partially contradictory aims creates tensions with the result that efforts are at times diverted from the aim of producing sustainable change and improvement. We suggest that a failure to understand these inner contradictions, together with unreflective policy interventions, may produce counterintuitive negative effects which hamper, instead of further, the cause of patient safety.
本文探讨了通过根本原因分析（Root Cause Analysis）调查临床事件所面临的挑战。我们在英国两家大型急症 NHS 医院进行了为期 18 个月的民族志研究，记录了事件调查、报告的过程，以及将结果转化为实践的过程。我们发现，这种方法既有优点也有问题。后者部分源于潜在不兼容的组织议程之间的矛盾，以及推动这种方法使用的社会逻辑。虽然根本原因分析最初被设想为一种组织学习技术，但它也被用作治理工具和在事件发生后重新确立组织合法性的一种方式。这些不同的、部分矛盾的目标的存在造成了紧张局势，导致有时工作偏离了产生可持续变革和改进的目标。我们认为，不了解这些内在矛盾，以及不加反思的政策干预，可能会产生适得其反的负面影响，阻碍而不是进一步促进患者安全。
