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RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
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RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

Report issued by the National Patient Safety Foundation




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NPSF Spotlight Series


Implementing RCA2: Lessons from the Trenches

The series begins October 4, 2016, and continues every Tuesday throughout the month.

Registration is now open. Get details here.


Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With a grant from The Doctors Company Foundation, NPSF convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses.


Download the full report here. [PDF]

This report or parts of it may be printed for individual use or distributed for training purposes within your organization.
No one may alter the content in any way, or use the report in any commercial context, without written permission from the National Patient Safety Foundation.

Inquiries should be addressed to


Numerous organizations have endorsed the use of RCA2: Improving Root Cause Analyses and Actions to Prevent Harm as a valuable resource in efforts to create a more effective event analysis and improvement system.


See Endorsements here.



Read answers to frequently asked questions about the processes and recommendations presented in the report.



Co-chairs of the panel that created the report, James Bagian, MD, PE, and Doug Bonacum, CSP, CPPS, discussed the report in a webcast on Wednesday, July 15, 2015. This webcast was funded by The Doctors Company Foundation.


Click here to download the webcast Presentation Slides [PDF]
Click here to download the webcast Audio [MP3]



The National Patient Safety Foundation gratefully acknowledges The Doctors Company Foundation for its critical and generous support of this project.

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