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Game-Changing Guidelines: RCA2

Posted By Administration, Thursday, July 23, 2015

More than 7,000 listeners tuned in to our webcast on improving root cause analyses—a clear indication that health professionals and organizations want help with their RCA process.



By Patricia McTiernan, MS


Root cause analyses have been used in health care for a long time, but the success of these investigations has been variable across organizations and the industry. As discussed at a July 15 webcast hosted by NPSF there has been a lack of standardization in the process, failure to identify systems-level causes, and, too many times, the solutions put in place after the event are not strong enough to fix the problem that caused it. On top of that, it is not unusual for busy health professionals to fail in following up to make sure the solutions they put in place are working as intended.


More than 7,000 listeners tuned in to the webcast, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, which provided an overview of the report of the same name that NPSF released in June. The high number of attendees for this session is a clear indication that health professionals and organizations want help with their RCA process.


  Jim Bagian, MD, PE
  Doug Bonacum, CSP, CPPS  
Speakers Jim Bagian, MD, PE, and Doug Bonacum, CSP, CPPS, NPSF board members who led the panel that drafted the new guidelines, began with an explanation of the report’s name. “RCA squared” refers to the fact that there are two As: root cause analyses and actions.


Root cause analysis, said Bagian, is a misnomer, because seldom is there only one root cause. Moreover, analysis does not solve anything by itself; more important is the fact that actions need to be taken to prevent future harm.


So what do the guidelines recommend? First of all, Bagian pointed out that RCA2 was put together to provide much-needed standardization and a road map for how to conduct a successful RCA that would result in effective and sustainable action that would prevent future harm to patients. The report received endorsement by a number of organizations from across the country in recognition of its value in enabling users to achieve greater impact for improving patient safety.


The purpose of an RCA2 is to find out what happened, why it happened, and what you are going to do to prevent it from happening in the future.


Bonacum summarized what he called the game-changers of this report:

  1. Use a risk-based prioritization scheme to determine what warrants an RCA2. A risk-based approach includes weighing the severity and likelihood of an event along with the actual or potential harm is poses. Risk-based prioritization allows examination of close calls, which can be a harbinger of an event.
  2. Involve patients and families. Those directly involved in the event should be interviewed to share their perspectives of what happened, but they should not be a part of the RCA2 team. The RCA2 team should include a patient/family representative—for example, a member of the hospital’s Patient and Family Advisory Council.
  3. Use an action hierarchy. The actions taken in the wake of an event and an RCA2 are the most important component, because strong actions will prevent the event from recurring. Warnings and increased training, for example, have historically been shown to be relatively weak in preventing a recurrence, while actions such as forcing functions or a simplified process that removes unnecessary steps is more likely to yield success.
  4. Involve the organization’s leadership and board. For the process to be successful, Bonacum said, it is critical that it be embraced at all levels of the organization, including the CEO and board of directors. This would involve, for example, the allocation of resources to conduct RCAs, but also the CEO’s review and approval of all actions recommended by the RCA2 team. Actions that are not approved should be documented so that the team knows why and can create another action that will be accepted. The report includes warning signs of an ineffective RCA, to help CEOs in their review.

NPSF thanks The Doctors Company Foundation for support of the production of the report and webcast. If you have not had a chance to read the report—or listen to the webcast replay—visit the web page.


Do you think the RCA2 guidelines will help improve root cause analysis in your organization? Comment on this post below (NOTE: you must be registered and logged in to this website to comment.)




James P. Bagian, MD, PE, is the director of the Center for Health Engineering and Patient Safety at the University of Michigan.

Doug Bonacum, CSP, CPPS, is vice president for Quality, Safety, and Resource Management at Kaiser Permanente.



Tags:  med errors  RCA  root cause analysis 

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