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PSNet: Patient Safety Network
Journal Article
Commentary

The problem with root cause analysis.

Peerally MF, Carr S, Waring J, et al. BMJ quality & safety. 2017;26:417-422.

Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health care. Discussing weaknesses associated with using RCAs, this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis quality, and insufficient feedback should be addressed to enhance the effectiveness of RCAs and sustain organizational learning from failure.