ABSTRACT
This chapter explores breakdowns in the evidence, information and knowledge (EI&K) pathway, and the potential for disastrous consequences that can ensue. It reviews the breakdown in the EI&K pathway using the root cause analysis (RCA) paradigm, and to present different options for performing the RCA. Root cause analysis is a tool for retrospective investigation that excels at dissecting where and why processes fail, and identifying the steps that need attention and repair. Breakdowns in the flow and interpretation of information and evidence are hardly unique to healthcare. Virtually every known man-made disaster includes examples of how failure to know, appreciate, and act on critical information at the right time played a role in causing the subsequent accident. The tragic case of research study volunteer Ellen Roche at Johns Hopkins University in 2001 has been noted as catastrophic example of EI&K breakdowns that culminated in the death of this 24-year-old laboratory technician.
