Patient safety and the RCA: A document analysis

Singh, Karen J. (2015) Patient safety and the RCA: A document analysis. PhD thesis, Queensland University of Technology.


This research examined the function of Queensland Health's Root Cause Analysis (RCA) to improve patient safety through an investigation of patient harm events where permanent harm and preventable death, Severity Assessment Code 1, were the outcome of healthcare. Unedited and highly legislated RCAs from across Queensland Health public hospitals from 2009, 2010 and 2011 comprised the data. A document analysis revealed the RCAs opposed organisational policy and dominant theoretical directives. If we accept the prevailing assumption that patient harm is a systemic issue, then the RCA is failing to address harm events in healthcare.

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335 since deposited on 27 Oct 2015
290 in the past twelve months

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ID Code: 87825
Item Type: QUT Thesis (PhD)
Supervisor: Windsor, Carol, Barnard, Alan, & Gardner, Glenn
Keywords: Patient Safety, Adverse Events, Healthcare, Clinical Incident, Reportable Event, Root Cause Analysis RCA, Safety
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Current > Schools > School of Nursing
Institution: Queensland University of Technology
Deposited On: 27 Oct 2015 05:26
Last Modified: 27 Oct 2015 05:32

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