A bottom-up approach to understanding the efficacy of event-analysis in healthcare

paradigm shift from safety to resilience engineering

Sudeep Hegde, A. Zach Hettinger, Rollin J. Fairbanks, John Wreathall, Vicky Lewis, Robert Wears, Ann M. Bisantz

Research output: Contribution to journalConference paper

6 Citations (Scopus)


Root Cause analysis (RCA) is a widely implemented event-analysis tool in healthcare, used to improve patient safety. Several studies have assessed the effectiveness of RCA solutions and provided recommendations for improving the approach; however few have suggested a systematic approach to align RCA-based interventions with the realities of work practice in healthcare. In this study, semi-structured interviews were conducted with frontline healthcare staff (nurses, nurse managers and technicians) in order to assess their perspectives on the effectiveness and sustainability of RCA-based solutions in a large academic medical center. In general, preventive interventions such as physical environment or equipment changes were more effective and sustainable than reactive or passive measures such as reviews and compliance checks. A thematic analysis of respondents' narratives highlighted several issues related to the design and implementation of various RCA-driven interventions. The analysis however, also revealed important facets of frontline medical practice, including the role played by staff in overcoming systemic hazards in order to increase patient safety. These findings are discussed in the context of the emerging Resilience Engineering approach to safety in complex systems.

Original languageEnglish
Pages (from-to)673-677
Number of pages5
JournalProceedings of the Human Factors and Ergonomics Society
Issue number1
Publication statusPublished - 2013
Externally publishedYes
Event57th Human Factors and Ergonomics Society Annual Meeting - 2013, HFES 2013 - San Diego, CA, United States
Duration: 30 Sep 20134 Oct 2013

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