National Patient Safety Foundation Releases Guidelines on Root Cause Analysis

The National Patient Safety Foundation recently released guidelines to help health care organizations investigate medical errors, adverse events, and near misses. Millions of patients

in the United States are harmed every year as a result of the health care they receive. In response, NPSF examined best practices around root cause analyses to create the guidelines— titled RCA2: Improving Root Cause Analyses and Actions to Prevent Harm—and determine why those errors occurred. The focus of the guidelines is to prioritize hazards based on the risk each poses to the patient.

“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,” says James P. Bagian, MD, PE, a member of the NPSF board of governors and director of the Center

for Health Engineering and Patient Safety at the University of Michigan. “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.”

A grant from the Doctors Company Foundation allowed NPSF to convene a panel of subject matter experts and stakeholders to examine best practices around RCAs, as well as to design guidelines to help health professionals standardize the process. Ronald M. Wyatt, MD, MHA, medical director, The Joint Commission, was part of the panel’s expert advisory group. The guidelines are to be discussed during a free web- cast July 15, 2015. For more information and to register for the webcast, visit http://www.npsf.org/?page=RCA2. P