Journal Article
Commentary

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

Iedema RAM, Jorm C, Braithwaite J, et al. Social science & medicine (1982). 2006;63:1201-12.

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.