While root cause analysis has been part of health care and patient safety for more than 15 years, success has been variable both within and across institutions. This module will review the process of Root Cause Analyses and Actions (RCA2) and its role in driving improvement in the process of reviewing events that cause or may cause serious harm, and in developing and implementing sustainable and measurable actions that prevent future harm to both patients and the workforce.
This two-part module will provide information and resources to educate health care professionals on the following key areas:
- Utilizing risk-based prioritization to select events for review
- Developing a systems-based, human factors approach to event review
- Choosing the correct team members and interviewees to participate in the RCA2 process
- Involving patients and families and senior leadership in RCA2
- Real-life strategies for implementing the RCA2 process across organizations and systems
This course is appropriate for physicians, nurses, health care executives, laboratory professionals, and quality and risk professionals.
Upon completion of the program, participants will be able to:
- Describe the key elements of the RCA2 process
- Explain the concept of risk-based prioritization and the application of tools to support the implementation of RCA2
- Identify best practices to support effective functioning of the RCA2 process within an organization
- Specify potential challenges to implementation and describe strategies to overcome barriers
Accreditation and Disclosures
This module has been accredited to offer the following Continuing Medical Education and Continuing Education contact hours. For more information, please click here.
- 1 contact hour for physicians
- 1 contact hour for nurses
- 1 contact hour for health care quality professionals
- 1 contact hour for professionals in health care risk management (This course has been submitted for review)
- 1 contact hour for health care executives (This course has been submitted for review)
- 1 contact hour for laboratory professionals
- 1 contact hour toward CPPS recertification
All event planners and presenters have disclosed in accordance with requirements. For more information, click here.
This module was developed utilizing the NPSF report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm and the presentations of the following individuals:
James P. Bagian, MD, PE
Center for Healthcare Engineering and Patient Safety
University of Michigan
Co-Chair, Root Cause Analyses and Actions (RCA2)
Jessica Behrhorst, MPH, CPHRM, CPHQ
Director of System Quality & Patient Safety
Ochsner Health System
Jeffrey B. Cooper, PhD
Executive Director Emeritus
Center for Medical Simulation
Professor of Anesthesia, Harvard Medical School
Maureen Anne Frye, MSN, BC, CRNP, CPPS, CPHQ
Center for Patient Safety and Healthcare Quality
Abington Jefferson Health
Erin Graydon Baker, MS, RRT, CPPS
Director of Risk Management
Patient Safety Officer
Maine Medical Center
Richard Guthrie, MD, CPE
System Chief Quality Officer
Ochsner Health System
Christina Lauro, RN, MSN
Healthcare Safety and Quality Consultant
Christina Lauro Consulting, LLC
Kathryn Rapala, JD, RN, CPPS
Vice President of Clinical Risk Management
Aurora Health Care
Sagar Sable, MPA/HSA
Patient Safety Program Manager
Quality Improvement Department
Cedars Sinai Medical Center
NPSF would like to acknowledge the following individuals for their special assistance with this project:
Kate Humphrey, MD, MPH
Fellow in Patient Safety & Quality
Boston Children’s Hospital and Harvard Medical School
NPSF would also like to note that publication of Implementing RCA2: Lessons from the Trenches was made possible thanks to a grant from The Doctors Company Foundation.
$39.99 $29.99 Special Introductory Price for Non-members
$19.99 ASPPS members, Stand Up for Patient Safety program members, and Patient Safety Coalition members
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- $19.99 American Society of Professionals in Patient Safety (ASPPS) members
- $19.99 Stand Up for Patient Safety program members and Patient Safety Coalition members
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After Your Purchase
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Contact us with any questions regarding course access or pricing.