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PSNet: Patient Safety Network
Journal Article

Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations.

Wrigstad J, Bergström J, Gustafson P. BMJ Open. 2014;4.

The effectiveness of root cause analysis (RCA) as a safety improvement tool has been called into question, as many institutions lack a formal mechanism for implementing and following up action items specified by RCAs. This Swedish study found that two factors predicted successful implementation of safety strategies after an RCA: management continuity and targeting corrective actions at the unit level (rather than at the organizational level).