Department of Surgery, University of South Florida, FL, USA.
Surg Clin North Am. 2012 Feb;92(1):89-100. doi: 10.1016/j.suc.2011.12.003.
This article describes the process of root cause analysis (RCA), the theories of error that underlie the concept of systemic or latent factors that allow errors to occur or to be propagated without correction; the difference between the process in health care and those found in high-reliability organizations; and suggests some ways to augment the standard health care RCA into a more robust and helpful process.
本文描述了根本原因分析（RCA）的过程，以及错误理论，这些理论是系统性或潜在因素概念的基础，这些因素允许错误发生或在未经纠正的情况下传播；医疗保健中的过程与高可靠性组织中发现的过程之间的差异；并提出了一些方法来增强标准医疗 RCA 成为更强大和有用的过程。
