کد مقاله کد نشریه سال انتشار مقاله انگلیسی نسخه تمام متن
954100 927625 2006 12 صفحه PDF دانلود رایگان
عنوان انگلیسی مقاله ISI
A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity
موضوعات مرتبط
علوم پزشکی و سلامت پزشکی و دندانپزشکی سیاست های بهداشت و سلامت عمومی
پیش نمایش صفحه اول مقاله
A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity
چکیده انگلیسی

This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into ‘root causes’, and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizational–managerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in ‘systems improvements’ assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care.

ناشر
Database: Elsevier - ScienceDirect (ساینس دایرکت)
Journal: Social Science & Medicine - Volume 63, Issue 5, September 2006, Pages 1201–1212
نویسندگان
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