Making sense of root cause analysis investigations of surgery-related adverse events

Surg Clin North Am. 2012 Feb;92(1):101-15. doi: 10.1016/j.suc.2011.12.008.


This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.

Publication types

  • Review

MeSH terms

  • Humans
  • Patient Safety*
  • Root Cause Analysis*
  • Surgical Procedures, Operative / adverse effects*