• PR:  National Patient Safety Foundation Releases Guidelines on Root Cause Analysis (PDF/QV) [REF: AOM, LDR, PI, ] Perspectives July 2014, Vol 35, #7, Pg 7 JCp1507_B2

“The National Patient Safety Foundation (NPSF), with support from The
Doctors Company Foundation, convened a panel of subject matter experts and stakeholders” (including TJC) for the purpose of identifying and improving the effectiveness of the Root Cause Analysis process. The primary focus of the desired improvement was on the prevention of future harm. Because “Prevention requires actions to be taken, and so (they) have renamed the process Root Cause Analysis and Action, RCA2 (RCA “squared”) to emphasize this point”.  The best practices that were determined from this work have been compiled as recommendations (pg 9) in a publication entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.  This publication is truly a treasure chest of best practice advice that includes:

• When it is and is not appropriate to blame an individual for an incident and the importance of that process being transparent (Think ‘Just Culture’ and the work on culpability by James Reason).

• What is the best size for an RCA team and who should be on it.

• Recommended steps and tools for conducting an effective RCA

• Suggested triggering questions and interviewing tips

The guide concludes with 7 appendices that provide practical tools, examples and scenarios for their use.
Tip: Start with a quick review of the recommendations on page 31 (Section IV). Then every QI/PI Director and/or person who conducts RCA’s should read and study sections I – III of these guidelines. Make a point of using this reference to help guide your next root cause analysis

See Also: Comments section of this article for additional information and a free webcast on RCA2