RCA2: Panel Report on Improving Root Cause Analyses and Actions to Prevent Harm

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

The panel’s 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 from happening again.

The RCA2 analysis seeks to identify system vulnerabilities so that they can be eliminated or mitigated and thus provide the most widely applicable and sustainable impact. The purpose of the review is not to assess individual performance (the goal of which is often to affix blame) but is instead on systems-based causes and solutions, since individual performance can merely be a symptom of larger systems-based issues. Findings from RCA2 efforts must not be used to discipline or punish staff, so that the trust in the system is not undermined. Individual performance is an administrative issue handled through other mechanisms independent of safety analysis findings.

The maximum benefit for the safety of the patient population occurs when system-based vulnerabilities are addressed. This benefit can be compromised if the RCA2 analysis and action process is perceived as a witch hunt. It is critical that each organization define the types of 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 managed using administrative or human resource systems.

Read the panel’s report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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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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