Using root cause analysis to improve patient safety

Patient Safety Monitor Insider

January 20, 2010

A recent post written by Bob Wachter, MD, on the widely popular KevinMD blog, talks about how his facility (UCSF Medical Center) has implemented a more thorough root cause analysis process in recent years, leading to what he describes as a "transformative process." Leaders at UCSF have decided to dedicate two hours each week to discussing any errors that have occurred, and why they did. Additionally, this same group hears reports of how plans that came out of the same meeting to prevent future errors are working—if the plans are successful, if they encountered any road blocks, and why they may not be working.

To read more about this process on the KevinMD blog, click here.