New RCA approach leans on prioritization and action to fix gaps in care

Patient Safety Monitor Insider

September 16, 2015

For years, hospitals have used root cause analysis (RCA) to identify gaps in their healthcare system that can lead to safety errors. The problem, according to some experts, is that the existing RCA process is inconsistent and often ineffective when it comes to the ultimate goal of prevention.

Earlier this year, the National Patient Safety Foundation (NPSF) convened a panel of safety experts from around the country to review and ultimately improve the RCA process. What they came up with was a new approach called Root Cause Analysis and Actions (RCA2) that focuses on prioritizing specific risks and identifying and implementing detailed action points to resolve gaps in patient safety.

This new approach was unveiled in a June report released by NPSF. In July, the panel's two co-chairs, James P. Bagian, MD, PE, director of the Center for Health Engineering and Patient Safety at the University of Michigan and Ann Arbor, and Doug Bonacum, CSP, CPPS, vice president of quality, safety, and resource management at Kaiser Permanente in Oakland, California, hosted a webcast to further explain some of the important changes to the risk analysis process.

During the webcast, Bagian and Bonacum emphasized the importance of the new "action" portion of the process, along with tweaks to the original RCA process that can help hospitals better identify systemic gaps and prioritize risks based on the likelihood and severity of patient harm. They argued that the previous RCA process often produced "superficial solutions," and that simply analyzing an event does not prevent it from recurring.

"The bottom line is how do we make a difference and actually prevent adverse events from happening to our patients?" Bagian said during the introduction. "That's the real goal here."

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