Improving the Capacity of Healthcare
Organisations to Act on Evidence in Patient Safety
Introduction
Safety has become an increasingly widespread concern in many Western healthcare sectors. In
the UK, Root Cause Analysis (RCA) - a structured process for investigating medical adverse
events - has been implemented along other initiatives to ascertain that “lessons are learned
across the NHS to prevent the same incidents occurring elsewhere’‘ (www.npsa.nhs.uk). The
assumption of RCA is that by identifying the systemic causes of medical adverse events and by
issuing recommendations, change and organisational learning will automatically ensue.
Adopting a practice-based perspective on learning, we critically inquire into this problemcentred approach of learning and aim to explore how RCA tries to find its place within a wider
net of nested work practices.
How is RCA conducted in practice?
What are the practical problems faced by healthcare
practitioners doing RCA?
RCA
Approach
Questions
Implement
Change
↔
What are the factors and conditions that facilitate or hamper the
capacity of structured methodologies, such as RCA, to produce learning
in healthcare organisation?
How are the work practices and professional identities of healthcare
professionals affected by the adoption of structured methods such as RCA?
What is the process through which innovative tools and techniques
travel between countries and sectors?
The study is of exploratory nature and combines direct observation,
interviews, and documentary analysis. For 18 months, we observe in two
acute trusts in the Midlands how patient safety/risk managers collaborate
with doctors, nurses, and other clinical staff to report, assess, and
investigate medical adverse events and how they implement their
recommendations for change. For the latter, we mainly rely on qualitative
interviews and ask how the RCA process is perceived in retrospect (right
after the conclusion of a RCA process and after 3 months) and what
Centralized vs. decentralized
investigation of incidents
About Us
Findings
•The organizing of RCA varies in terms of locus
of control and management. What are the
implications for learning?
Global Travel of RCA
Centralised vs. decentralised investigation of incidents
What
theRCA
RCA
process
Understanding
whatis
is the
process
effectively about
Learning at the
fringes
effectively
about?
Allocation of Risk, Responsibility, Authority
• Is the object of activity of RCA learning,
experimentation, and change, or is it (also)
closure, consensus, and control?
IKON (the Innovation, Knowledge and Organizational Networks research
unit) is a research network based at Warwick Business School. Its
members carry out funded research projects on the creation, translation
and adoption of organizational and technological innovations, knowledge
and practices. IKON studies these processes mainly, albeit not exclusively,
in the biomedical and healthcare sectors.
the changes are to which it led. In order to better understand how RCA is
becoming embedded and changing clinical work (i.e. the resistances it
generates, the new patterns of relationship), we compare the practices of
and around RCA across various clinical departments. Finally, we engage in
discourse analysis of the more formal interactions (i.e. documented
responses to action plans) and more flexible encounters (i.e. informal
conversations during visits) between the patient safety group and the
clinicians.
Learning at the Fringes
• With the introduction of RCA what new
patterns of relationship, forms of discursivity,
and sites of learning do emerge?
The Global Travel of RCA
• We found that the widespread diffusion and
translation of RCA derives from its capacity to
serve as an “easy fix to many woes”.
Project members:
Davide Nicolini (WBS), Justin Waring (Nottingham), Jeanne Mengis (WBS),
Jacky Swan (WBS), Juliane Schwarz (WBS), Peter Spurgeon (WMS)
Visit IKON at: www.warwick.ac.uk/go/ikon
Contact Us
Dawn Coton
Research Project Co-ordinator
Dawn.Coton@wbs.ac.uk
+44(0)24 7652 4503
Sponsor of the Project