Saying, “We can do better,” Jim Bagian declared that root cause analysis (RCA)—the subject of a new report by the National Patient Safety Foundation (NPSF)—offers uncommon potential to improve safety and that, in general, healthcare has not used it well and wasted opportunities to prevent future harm.
Bagian and Doug Bonacum were co-chairs of the working group that developed the new report for NPSF. They also led “Patient Safety Science: Successful Practices to Optimize Root Cause Analysis,” an all-day workshop offered the day before NPSF’s annual Patient Safety Congress, held earlier this year in Austin, Texas. With their time and lively discussion, those who attended the workshop endorsed Bagian’s sentiments about “doing better.”
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