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Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant

2002; BMJ; Volume: 11; Issue: 3 Linguagem: Inglês

10.1136/qhc.11.3.266

1475-3901

John S. Carroll,

Innovation and Knowledge Management

Root cause analysis was introduced to a chemical plant as a way of enhancing performance and safety, exemplified by the investigation of an explosion. The cultural legacy of the root cause learning intervention was embodied in managers9 increased openness to new ideas, individuals9 questioning attitude and disciplined thinking, and a root cause analysis process that provided continual opportunities to learn and improve. Lessons for health care are discussed, taking account of differences between the chemical and healthcare industries.