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Key Publications
Some publications for further information.
Further reading
Anderson, J. E., & Kodate, N. (2015). Safety Science
Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness.
Bowie P, Skinner J, de Wet C. (2013) BMC Health Serv Res
Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.
Braithwaite J Westbrook MT Mallock NA, et al. (2006) Qual Saf Health Care
Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.
Cacciabue, P.C., Oddone, I. (2014) Cogn Tech
Sidney Dekker: The field guide to understanding ‘Human Error’
Card, Alan J., James Ward, and P. John Clarkson (2012) Journal of Healthcare risk management
Successful risk assessment may not always lead to successful risk control: a systematic literature review of risk control after root cause analysis
Carayon, P. A. S. H., et al. (2016) BMJ Quality & Safety
Work system design for patient safety: the SEIPS model
Cooper J, Edwards A, Williams H, Sheikh A et al. (2017) Ann Fam Med
Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database
Drupsteen L, Groeneweg J, Zwetsloot GI. (2013) Int J Occup Saf Ergon
Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention
Drupsteen L. Guldenmund, F W
What Is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents and Disasters
Hibbert PD Thomas MJW Deakin A, et al. (2018) Int J Qual Health Care.
Are root cause analyses recommendations effective and sustainable? An observational study
Hibbert PD, Stewart S, Wiles LK, Braithwaite J, Runciman WB, Thomas MJW. (2023) Int J Qual Health
Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts.
Liberati EG, Peerally MF, Dixon-Woods M. (2018) Int J Qual Health Care.
Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare
Lim, Rosemary and Hide, Sophie and Akanbi et al.
Development Of A Competency Framework for Healthcare Safety Investigators: An E-Delphi Study
Lea W, Lawton R, Vincent C, O'Hara J. (2023) J Patient Saf.
Exploring the "Black Box" of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review
Lea W, Budworth L, O'Hara J, et al. (2026) BMJ Quality & Safety
Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
Nicolini D, Waring J, Mengis J. (2011) Soc Sci Med
Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap
Leistikow I, Mulder S, Vesseur J, Robben P. (2017) BMJ Qual Saf
Learning from incidents in healthcare: the journey, not the arrival, matters
Louch G, Macrae C, Talbot R, McHugh S, O'Hara JK. (2025) J Patient Saf.
How Were Patient Safety Incidents Responded to, Investigated, and Learned From Within the English National Health Service Before the Implementation of the Patient Safety Incident Response Framework? A Rapid Review
Lounsbury O, Tomlinson A, Wakeling J, Bowie P, Higham H. (2025) Front Health Serv
The use of healthcare simulation to identify and address latent safety threats: a scoping review
O'Hara JK, Lawton RJ. (2016) BMJ Qual Saf.
At a crossroads? Key challenges and future opportunities for patient involvement in patient safety
O'Hara JK, Canfield C. (2024) The Lancet
The future of engaging patients and families for patient safety
Ramsey L, McHugh S, Simms-Ellis R, Perfetto K, O'Hara JK. (2022) J Patient Saf.
Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence
Sampson P, Back J, Drage S. (2021) BJA Educ
Systems-based models for investigating patient safety incidents
Trbovich, Patricia, and Kaveh G. Shojania. (2017) BMJ quality & safety
Root-cause analysis: swatting at mosquitoes versus draining the swamp
Wailling J, Kooijman A, Hughes J, O'Hara JK. (2002) Health Expect.
Humanizing harm: Using a restorative approach to heal and learn from adverse events
Waterson P. (2021) Int J Qual Health Care.
Promoting systemic incident analysis in healthcare—key challenges and ways forwards
Weaver S, Stewart K, Kay L. (2021) Future Healthc J.
Systems-based investigation of patient safety incidents
Wiig S, Braithwaite J, Clay-Williams R. (2020) Int J Qual Health Care.
It’s time to step it up. Why safety investigations in healthcare should look more to safety science
Wood LJ, Wiegmann DA. (2020) Int J Qual Health Care.
Beyond the corrective action hierarchy: a systems approach to organizational change
Wrigstad J, Bergström J, Gustafson P. (2014) BMJ Open.
Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations
Paul Bowie, Melanie Ottewill, Rosemary Lim, Tracey Herlihey et al. (2025) medRxiv
Development and validation of a tool to aid writing and reviewing of healthcare safety investigation reports: a modified-Delphi study
P Bowie, E McNaughton, D Bruce et al. (2016) Journal Continuing Education in the Health Professions
Enhancing the effectiveness of significant event analysis: exploring personal impact and applying systems thinking in primary care
Paul Bowie, Alistair Ross, Thomas Purchase et al. (2023) Journal of Personal Injury Law
Patient safety learning for healthcare improvement: considering the" system context" in medico-legal cases?
Peerally MF Carr S Waring J, et al. (2017) BMJ Qual Saf.
The problem with root cause analysis
- The problem with root cause analysis ( Download, 528 KB)
Peerally MF, Carr S, Waring J, Martin G, Dixon-Woods M. (2024) J Patient Saf.
Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study
Plsek PE, Greenhalgh T. (2001) BMJ.
Complexity science: the challenge of complexity in health care
Vincent C, Carthey J, Macrae C, et al. (2017) Implementation Science.
Safety analysis over time: seven major changes to adverse event investigation
Vincent CA. (2004) Qual Saf Health Care.
Analysis of clinical incidents: a window on the system not a search for root causes