Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.
With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses. To improve the effectiveness and utility of these efforts, the Institute of Healthcare Improvement have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so they have renamed the process Root Cause Analyses and Actions, or RCA2 (RCA “squared”) to emphasise this point.
The purpose of this document is to ensure that efforts undertaken in performing RCA2 will result in the identification and implementation of sustainable systems-based improvements that make patient care safer in settings across the continuum of care. The approach is two-pronged:
- Identify methodologies and techniques that will lead to more effective and efficient RCA2.
- Provide tools to evaluate individual RCA2 reviews so that significant flaws can be identified and remediated to achieve the ultimate objective of improving patient safety.
The purpose of an RCA2 review is to identify system vulnerabilities so that they can be eliminated or mitigated; the review is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues.