Adverse events: root causes and latent factors.
Surg Clin North Am. 2012 Feb;92(1):89-100
Authors: Karl R, Karl MC
This article describes the process of root cause analysis (RCA), the theories of error that underlie the concept of systemic or latent factors that allow errors to occur or to be propagated without correction; the difference between the process in health care and those found in high-reliability organizations; and suggests some ways to augment the standard health care RCA into a more robust and helpful process.
PMID: 22269263 [PubMed - indexed for MEDLINE]