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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.

RCA2 is a trademark of the Institute for Healthcare Improvement (IHI). IHI does not endorse any software or training for the RCA2 process that is not directly provided by IHI





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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, the National Patient Safety Foundation 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.


To improve the effectiveness and utility of these efforts, we have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so we have renamed the process Root Cause Analyses and Actions, or RCA2 (RCA “squared”) to emphasize this point.


Download the full report. [PDF]


Suggested citation for this publication: National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Available at



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.


Online Learning Module

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.


Access the module to hear more about the RCA2 process and learn from exemplary organizations implementing the RCA2 recommendations.



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 July 15, 2015. This webcast was funded by The Doctors Company Foundation.


The webcast slides and audio are available for complimentary download in our Online Store.



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

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