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Frequently asked questions about the processes and recommendations presented in the NPSF report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
Q. What does the RCA2 team do?
A. The RCA2 team should be officially charged by leadership (preferably
the CEO, COO, or CMO) with investigating the adverse event to discover
underlying system issues that contributed to or resulted in the event
occurring. The work associated with the RCA2 process should not be
considered “additional duties as assigned”; team members should be given
time during their normal work schedule to complete their assignments.
Team members who are given time to do the work but do not complete it
should be held accountable by leadership as they would if their regular
assignments/duties were not being completed.
Q. Who do you consider to be the team members on an RCA2 team?
A. The RCA2 team members are those who are assigned by the organization’s leadership to officially serve on the team. These are the individuals who attend all of the meetings, conduct the research, interview staff, identify root cause contributing factors, and write the report. In most cases this team also identifies the corrective actions and their associated process/outcome measures, though in some organizations an individual or another team may complete this task.
Q. Why do you recommend that staff involved in the event not be a member of the RCA2 team?
A. When we use the term “member of the RCA2 team” we are specifically referring to those individuals who have the ultimate decision-making authority regarding the final output of the RCA2. Some people refer to these individuals as the voting members of the team. In order to understand what happened and why it happened, it is necessary to talk openly during the team meetings about the actions of those individuals immediately involved in the event. If those involved are part of this discussion, other team members may refrain from speaking up or may self-censor what they say in order to spare these individuals from further mental anguish or to avoid hurting their feelings.
Q. Why do you recommend that patients involved in the event or their family not be members of the RCA2 team?
A. As in the answer above, when we use the term “member of the RCA2 team,” we are specifically referring to those individuals who have the ultimate decision-making authority regarding the final output of the RCA2. It is absolutely appropriate to interview the involved patient and/or the patient’s family members in most cases. Patients and families can provide helpful information to the RCA2 team as the team considers actions they think should be implemented to prevent a recurrence of the event.
Q. It looks like implementing a risk-based prioritization system is going to increase the number of events that will require root cause analysis and action review. How do you recommend this be addressed?
A. Using a risk-based prioritization system and scoring each event to determine its actual and potential score (based on the most likely worst-case outcome for your specific organization), as described in the report, may identify additional events requiring review. Prioritize the work based upon the score with the most severe actual events being reviewed first working toward the least severe potential events, as resources permit. It is highly recommended that an aggregated review program be established. This may be accomplished by prospectively identifying categories of frequently occurring potential SAC 3 events, sometimes called close calls, (e.g., falls, medication adverse events) and establishing a system to collect basic data as they occur, which will be needed to review them.
Q. How do I get leadership involved in the RCA2 process?
A. With the RCA2 guidelines, it is essential that the Board and CEO are fully engaged in and supportive of the investigation and improvement process. It is the responsibility of the senior risk and safety leadership to inform and educate executives about the importance of the RCA2 process and to illustrate how the process can lead to organization-wide improvements to safety. It is essential to emphasize the future risk mitigation that can result from a robust process. Presenting a “business case” for safety can also be a useful tool. One strategy to promote leadership engagement is bringing root cause analysis cases and action items to the highest level quality committee meetings as well as to board meetings, so leaders can truly understand the types of events occurring and the importance of a robust RCA2 process.