A paper on the application of REASON® Root Cause Analysis for

Child Protection Adverse Outcome Investigations has been published in:

Children and Youth Services Review

Volume 27, Issue 4, April 2005, Pages 393-407

Examining Decision Errors in Child Protection:

A New Application of Root Cause Analysis

By Tina L. Rzepnicki*

and Penny R. Johnson.  University of Chicago 

A version of this paper was presented at the

Third International Symposium: Decision Making in Child Welfare,

University of California a Berkeley.  December 4, 2003.

BACKGROUND

In November of 2002, Decision Systems Inc., the REASON® software developers, were contacted by Professor Tina Rzepnicki with the University of Chicago.

Professor Rzepnicki  was interested in determining the applicability of root cause analysis for systematically identifying decision errors in cases of child death involving families already known to the state public child protection agency.

The goals of her project were to establish an approach that would:

1)       Provide a repeatable process to which investigators of the child deaths could bring their skills and experience.

2)       Establish a set of criteria for supporting thorough and uniform data collection, and

3)       Establish an analytic method that would permit the identification of common patterns of error across cases.

Professor Tina Rzepnicki decided to deploy the REASON® Root Cause Analysis and Lessons Learned System. From that resource of activity and study came a personal interest by Professor Rzepnicki and her co-author Penny R. Johnson in the broader potentials of root cause analysis. The paper referred to above is now is a result of that professional curiosity and interest, and is provided for reference with the permission of the authors.

For persons involved in human behavior analysis and research, this paper provides insights to the dynamics within organisations that are generated through the interaction of individuals with the demands of critical responsibility, the personal dispositions of those individuals and the processes within the organisation itself.

With the authors permission we are happy to provide a PDF download of the pre-published paper for comments and feedback to the authors. 

* Contact information: Tina Rzepnicki, Professor, School of Social Service Administration,

  University of Chicago, 969 E. 60^th St., Chicago, Illinois 60637,

  phone: 773-702-1426, e-mail: t-rzepnicki@uchicago.edu

The publishers link for the full final version of this paper is:

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