RCA²: Panel Report on Improving Root Cause Analyses and Actions to Prevent Harm

James P. Bagian, MD, PE, member of The Doctors Company Board of Governors, co-chaired a panel with the National Patient Safety Foundation, funded by a grant from The Doctors Company Foundation, to improve how we can learn from adverse events and unsafe conditions and take action to prevent their occurrence in the future. This panel of subject matter experts and stakeholders worked to improve the root cause analysis (RCA) process in settings across the continuum of care.

The result was the RCA^{2 SM} (RCA “squared”) process. Traditionally, RCA has had inconsistent success. To improve the effectiveness and utility of these efforts, the panel focused on the ultimate objective: preventing future harm. Prevention requires actions to be taken. The RCA² process identifies those actions and provides guidance on implementing and verifying their effectiveness.

“We’ve created a process that includes action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone's time. A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care.”

—Dr. Bagian

The panel’s report describes how RCA² analysis can credibly and effectively be used to prioritize the events, hazards, and vulnerabilities in systems of care to accomplish the real objective—which is to understand what happened, why it happened, and then take positive action to prevent it from happening again.

The RCA² analysis seeks to identify system vulnerabilities so that they can be eliminated or mitigated and thus provide the most widely applicable and sustainable impact. The purpose of the review is not to assess individual performance (the goal of which is often to affix blame) but is instead on systems-based causes and solutions, since individual performance can merely be a symptom of larger systems-based issues. Findings from RCA² efforts must not be used to discipline or punish staff, so that the trust in the system is not undermined. Individual performance is an administrative issue handled through other mechanisms independent of safety analysis findings.

The maximum benefit for the safety of the patient population occurs when system-based vulnerabilities are addressed. This benefit can be compromised if the RCA² analysis and action process is perceived as a witch hunt. It is critical that each organization define the types of blameworthy events and actions that fall outside the purview of the safety system and define how and under what circumstances they will be handled or managed using administrative or human resource systems.

Read the panel’s report, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm.