RCA2: Improving 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.

Traditionally, the process employed to accomplish this learning has been called RCA, but it 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, and so the panel renamed the process Root Cause Analysis and Action, RCA2 (RCA “squared”) to emphasize this point.

“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. 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 methodologies and techniques that an organization or individuals involved in performing an RCA2 can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their 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 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. Root cause analysis and action 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 root cause 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.

This report answers questions integral to patient safety and the root cause analysis process including how to:

  • Triage adverse events and close calls/near misses
  • Identify the appropriate RCA2 team size and membership
  • Establish RCA2 schedules for execution
  • Use tools provided here to facilitate the RCA2 analysis
  • 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 RCA2 process

The RCA2 guidelines have received support from the healthcare community worldwide, with endorsements from the Canadian Patient Safety Institute, the Institute for Safe Medication Practices, Citizens for Patient Safety, and Children’s Health Queensland.


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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