Examining decision errors in child protection: A new application of root cause analysis

This paper describes a project whose goals are to uncover decision errors in child protection investigations and trace their origins in cases where children have died during or after an investigation. Root cause analysis, the method chosen for examining project cases, was originally designed to reveal multi-level factors contributing to negative outcomes in other high risk enterprises, such as chemical factory explosions, airline crashes, and failed military operations. To our knowledge, it has not been applied to the study of decision making in human services. An illustration of its use with a case example serves as a springboard for a discussion of the particular approach to analysis we chose, application issues, and implications for practice.