Napa, California—June 16, 2015—Root cause analysis (RCA) guidelines were issued today by the National Patient Safety Foundation (NPSF) through the sponsorship of The Doctors Company Foundation. The guidelines were developed to help healthcare organizations improve the way they investigate errors, adverse events, and near-misses.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm was funded by a grant from The Doctors Company Foundation. James P. Bagian, MD, PE, member of the Board of Governors of The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, co-chaired the panel of experts who developed the guidelines. Dr. Bagian also serves on the NPSF Board of Governors and is director of the Center for Health Engineering and Patient Safety at the University of Michigan.
“We’ve renamed the process RCA2—RCA squared—with the second ‘A’ meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone’s time,” Dr. Bagian said. “A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care.”
The guidelines have been endorsed by the healthcare community worldwide, including endorsements from The Joint Commission, Institute for Safe Medication Practices, Institute for Healthcare Improvement, ECRI Institute, and The Doctors Company.
“Many organizations spend significant resources performing root cause analyses; however, these often are not performed optimally, which can lead to failure to improve the systems that contributed to the event,” said David B. Troxel, MD, chairman of the board of The Doctors Company Foundation and medical director at The Doctors Company. “By funding these guidelines, The Doctors Company Foundation is helping to ensure that organizations learn from adverse events and close calls and successfully improve systems to minimize the occurrence of these events in the future.”
The Doctors Company Foundation is also sponsoring a webcast on the guidelines scheduled for 1:00 PM (ET) on Wednesday, July 15. The free webcast will feature Dr. Bagian and Doug Bonacum, CSP, CPPS, vice president, Quality, Safety, and Resource Management, Kaiser Permanente. Mr. Bonacum co-chaired the development of the guidelines with Dr. Bagian and also serves on the NPSF Board of Directors.
About The Doctors Company Foundation
The Doctors Company Foundation was created in 2008 by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. The purpose of the Foundation is to support patient safety education for healthcare professionals, patient safety research with clinically useful applications, and medical professional liability research. In this context, patient safety is defined as a healthcare discipline that minimizes the incidence and impact of adverse events by redesigning systems and processes using human factors principles to reduce errors.