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09/18/26

Beyond root cause analysis: a practical systems engineering approach to incident investigation in histopathology.

Rakha, Omar E; Rakha, Emad A. J Clin Pathol.

Collection Topics
Measurement, Monitoring, and Event Analysis Tests, Screening, and Laboratory Processes
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Summary

Diagnostic incidents require investigations that identify system vulnerabilities including whether the response is proportional to the severity of the error. This UK-focused narrative review applies systems engineering principles to incident investigation in histopathology. It discusses approaches for understanding how work conditions, processes, and organizational factors contribute to errors. Although developed for pathology, the framework may inform broader diagnostic safety investigations.
Read the paper
Rakha OE, Rakha EA. Beyond root cause analysis: a practical systems engineering approach to incident investigation in histopathology. J Clin Pathol. 2026;79(10):649-658.