Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error

In this paper, we discuss how a technique borrowed from defense and manufacturing is being deployed in hospitals across the industrialized world to investigate clinical errors. We open with a discussion of the levers used by policy makers to mandate that clinicians not just report errors, but also gather to investigate those errors using root cause analysis (RCA). We focus on the tensions created for clinicians as they are expected to formulate 'systems solutions' that go beyond blame. In addressing these matters, we present a discourse analysis of data derived during an evaluation of the NSW Health Safety Improvement Program. Data include transcripts of RCA meetings which were recorded in a local metropolitan teaching hospital. From this analysis we move back to the argument that RCA involves clinicians in 'immaterial labour', or the production of communication and information, and that this new labour realizes two important developments. First, because RCA is anchored in the principle of health care practitioners not just scrutinizing each other, but scrutinizing each others' errors, RCA is a challenging task. Second, thanks to turning the clinical gaze in on the clinical observer, RCA engenders a new level of reflexivity of clinical self and of clinical practice. We conclude with asking whether this reflexivity will lock the clinical gaze into a micro-sociology of error, or whether it will enable this gaze to influence matters superordinate to the specifics of practice and the design of clinical treatments; that is, the over-arching governance and structuring of hospital care. (c) 2005 Elsevier Ltd. All rights reserved.