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Implementing Root Cause Analysis and Actions: Lessons Learned from the Journey

Posted By Administration, Tuesday, May 16, 2017
Updated: Monday, May 15, 2017

In a breakout session at the upcoming NPSF Patient Safety Congress, members of the Ochsner Health System team detail their effort to implement RCA2.

by Joanna Carmona

As Jessica Behrhorst, system director of quality and patient safety at Ochsner Health System admits, Root Cause Analysis and Actions (RCA2) seemed like an intimidating process before they started implementation in their 13-hospital health care system with more than 1,000 employed physicians and a non-employed medical staff of over 2,000. However, after taking the time to learn about RCA2 and teach it to their team, the health care staff at Ochsner is a lot more open to talking about the process, which has now been added to their regular toolkit. But the question is: how did they get there?


At this year’s NPSF Patient Safety Congress, Ms. Behrhorst and Richard D. Guthrie, Jr., MD, CPE, chief quality officer at Ochsner Health System, will describe their journey through the implementation of the new Root Cause Analysis and Actions model and what they’ve learned in the process.


“When we started in 2015, we were very aware that we couldn’t do RCA2 in a vacuum—it had to be part of a larger cultural change,” said Ms. Behrhorst. “We could put the pieces into place, but if we didn’t have a culture of reporting or trust from our staff that we were going to do something with those reports, we knew we wouldn’t be successful.”


One of the first successes they saw was a significant increase in the number of RCAs being performed including some RCAs on good catches that they may not have done in the past. For example, the team at Ochsner had seen several events where surgical equipment was coming back with bioburden. The equipment never touched or harmed a patient and was sent to get reprocessed, but staff started reporting it, so they used the sterilization process for the RCA2. The team had found enough risk by using the risk-based prioritization matrix that they thought a change in the process was necessary, allowing them to effect change in an area where a patient could have been harmed. 

Jessica Behrhorst

Richard Guthrie,

chief quality officer,

Ochsner Health System

Jessica Behrhorst

system director

of quality and

patient safety,

Ochsner Health System

Many of the tools Ochsner uses for RCA2 have come directly from the 2015 NPSF report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Ochsner Health System created three distinct presentations based on the report in order to get the health care team up to speed and on board with the complex processes: one was created for leaders in the RCA2 team, another is specifically for team member briefings, and one holds the electronic version of the tools from the RCA2 report. 

Not only has implementing RCA2 proven to be successful within their own system but it has also become a way to share events and experiences with other facilities. Every month, Ochsner hosts a system quality meeting that includes chief nursing officers from across the system, their vice president of medical affairs, and performance improvement and pharmacy leaders. In that meeting, participants started sharing RCA events and the findings from those RCAs. As a result, teams started learning a lot from the sharing, particularly in instances when they found out that other facilities had faced similar events and could share tools to help mitigate the problem. The lasting effect was helping systems recognize that they are not operating in silos.While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

In the spirit of not operating in silos, Session 301 will share lessons learned from the two years they have implemented RCA2, so that others may learn from their challenges and successes. 

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Do you have any lessons learned to share from implementing RCA2 in your institution? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Joanna Carmona is communications coordinator at the National Patient Safety Foundation at Institute for Healthcare Improvement. Contact her at

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Tags:  2017 Patient Safety Congress  RCA 

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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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