ABSTRACT

This chapter examines the results of an in-depth ethnographic study of the application of root cause analysis (RCA) in several large hospitals within the English National Health Service. It explores how RCA practices and procedures are undertaken with the intention of identifying the barriers to successful learning and recommendations for service development. The chapter discusses some of the implications these challenges have for organizational learning. It describes the vision of RCA as outlined in the literature and policy and also discusses the perspective of organizational learning that this approach reflects. The chapter highlights the major challenges of implementing RCA on the ground. Investigators faced several challenges in the early stages of the RCA process, from securing the willing participation of staff, to being confident of the quality of information contained within records and statements and dealing with the ambiguity of clinical 'facts'.