In the almost two years that I’ve served as president of the National Patient Safety Foundation, one of the topics I’ve heard about a lot is the challenge of conducting an effective root cause analysis (RCA). Who decides when an RCA is needed? Who is on the investigatory team? How do we focus on systems and not appear to be on a hunt to assign blame?
With a grant from The Doctors Company Foundation, NPSF recently convened an expert panel to look at these and other challenges and to develop guidelines to help health care professionals and their organizations improve the way they conduct RCAs. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is available as of today on the NPSF website, and I hope you’ll take the time to review this useful document.
This report provides a structure and brings together tools to help in the RCA process. In my estimation, the three chief recommendations to absorb are…
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