A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

Roderick Aren Michael Iedema; Christine Jorm; Jeffrey Braithwaite; Jo Travaglia; Martin Lum

Commentary

A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

May 31, 2006

Iedema RAM, Jorm C, Braithwaite J, et al. Soc Sci Med. 2006;63(5):1201-12.

View more articles from the same authors.

The authors present the results of a root cause analysis (RCA) of an accidental morphine overdose and discuss challenges the team faced in using RCA to understand the error. They conclude that the process is most useful in its ability to facilitate multidisciplinary, specific discussions to improve the delivery of care.

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A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

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A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity.

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