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PSNet: Patient Safety Network
Journal Article

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes.

Smits M, Janssen J, de Vet R, et al. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2009;21:292-300.

Root cause analysis is commonly used to identify underlying system causes of adverse events. However, this study found that interrater agreement on the number and type of root causes was only moderate.