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PSNet: Patient Safety Network
Journal Article
Study

Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap.

Nicolini D, Waring J, Mengis J. Social science & medicine (1982). 2011;73:217-25.

This study explores the tensions between the theory of root cause analysis and its use in practice. While the tool was designed to generate organizational learning, the authors argue that contradictory agendas observed provide an opportunity to reevaluate its application.