RCA2: Training to Improve Root Cause Analyses and Actions to Prevent Harm

Guidelines for Healthcare Organizations to Improve Investigating Errors, Adverse Events, and Near-Misses

James P. Bagian, MD, PE, member of The Doctors Company Board of Governors, co-chaired a panel with the National Patient Safety Foundation, funded by a grant from The Doctors Company Foundation, to improve how we can learn from adverse events and unsafe conditions and take action to prevent their occurrence in the future. This panel of subject matter experts and stakeholders worked to improve the root cause analysis (RCA) process in settings across the continuum of care.

The result was the RCA2 SM (RCA “squared”) process. Traditionally, RCA has had inconsistent success. To improve the effectiveness and utility of these efforts, the panel focused on the ultimate objective: preventing future harm. Prevention requires actions to be taken. The RCA2 process identifies those actions and provides guidance on implementing and verifying their effectiveness.

“We’ve created a process that includes action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone's time. 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.”

—Dr. Bagian

This report describes how RCA2 analysis can credibly and effectively be used to prioritize the events, hazards, and vulnerabilities in systems of care to accomplish the real objective, which is to understand what happened, why it happened, and then take positive action to prevent it happening again.

The RCA2 analysis seeks 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. Team findings must not be used to discipline or punish staff, so that the trust in the system is not undermined. The maximum benefit for the safety of the patient population occurs when system-based vulnerabilities are addressed, and this can be compromised if the RCA2 analysis and action process is viewed as a witch hunt. It is critical that each organization define blameworthy events and actions that fall outside the purview of the safety system and define how and under what circumstances they will be handled or dealt with using administrative or human resource systems.

RCAAnalysis Training

The Doctors Company is pleased to offer customized RCAanalysis training to improve patient safety and care by helping healthcare organizations identify appropriate actions based on an RCA analysis process. This training will cover how to:

  • Triage adverse events and close calls/near misses
  • Identify the appropriate RCA team size and membership
  • Establish RCA schedules for execution
  • Use tools provided here to facilitate the RCA analysis and add in the action step
  • Identify effective actions to control or eliminate system vulnerabilities
  • Develop Process/Outcome Measures to verify that actions worked as planned
  • Use tools provided here for leadership to assess the quality of the RCA process

To access this training, contact our Patient Safety team.


James P. Bagian,

In addition to serving as a member of The Doctors Company Board of Governors, Dr. Bagian is the director of the Center for Healthcare Engineering and Patient Safety and a professor in the Medical School and the College of Engineering at the University of Michigan. He is also a diplomate of the American Board of Preventive Medicine; a member of the NASA Aerospace Safety Advisory Panel, National Academy of Engineering, and National Academy of Medicine.

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