Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error.
This study discusses the translocation of root cause analysis (RCA) techniques from non-health care settings and how this method leads to new roles and participation among clinicians in more clearly understanding health care systems and the errors they produce. The authors explain the contextual factors driving a commitment to quality and safety as a platform to discuss techniques of conducting RCAs. This discussion is illustrated with actual excerpts from an RCA, after which the authors analyze the roles each participant played, the tensions that exist, and the new communication patterns that resulted. The authors suggest the need to address challenges in conducting RCAs but also raise the question of whether they will serve to foster relationships between clinicians and management in moving patient safety efforts forward.