Search our Site
Implementing RCA2: Lessons from the Trenches
Share |

Quick Links 

  Course Purchase Information  
  Launch Course  


 Download the report
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm



NPSF thanks The Doctors Company Foundation for their generous support of this program. 



Course Description

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

Target Audience 


This course is appropriate for physicians, nurses, health care executives, laboratory professionals, and quality and risk professionals.

Learning Objectives

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 
  • contact hour for nurses
  • 1 contact hour for health care quality professionals
  • 1 contact hour for professionals in health care risk management 
  • contact hour for health care executives 
  • 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

Module Faculty

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

Abington-Jefferson Health

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
Associate Medical Director of Patient Safety
Boston Children’s Hospital


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

Purchase the Course

$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



  1. Click here to sign in to the website.
  2. Click here to purchase the course in our online store. After signing in you will automatically receive pricing which coincides with your member level listed below.
  • $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


  1. Click here to create a user account on our website.
  2. Sign in to the website.
  3. Click here to purchase the course in our online store after you've created your user account. We will not be able to grant access to the course until you've created a user account.
  • $29.99 Non-members

After Your Purchase

  • After you purchase the course in our online store you'll receive an e-mail receipt.
  • Please allow 1-2 business days for us to activate your online learning account.
  • We'll e-mail you when your online account is activated and you've be granted access to the course.

Contact Us 

Contact us with any questions regarding course access or pricing.

Click on the  Group Pages menu icon above to jump to any page in the course.



more Calendar

WIHI: Taking Acute Pain Seriously, Treating It Safely

10/24/2019 » 10/30/2019
Patient Safety Executive Development Program

Copyright ©2019 Institute for Healthcare Improvement. All Rights Reserved.

Membership Software  ::  Legal