NPSF issues root cause analysis guidelines


The National Patient Safety Foundation (NPSF) has released guidelines developed to help health care organizations improve the way they investigate medical errors, adverse events, and near misses. 

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm has been endorsed by a number of related organizations and is being widely distributed to hospitals, health systems, and other settings.

With a grant from The Doctors Company Foundation, NPSF 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.

"NPSF heard from many health professionals about the need for best practices around RCA," said Dr Tejal Gandhi, president and chief executive officer, NPSF. "We wanted to help those in the field improve their processes with a standardized approach and with the ultimate goal of preventing harm."

Dr James Bagian, a member of the NPSF board of governors and director of the Center for Health Engineering and Patient Safety at the University of Michigan, served as co-chair of the expert panel along with Doug Bonacum, vice president, Quality, Safety, and Resource Management, Kaiser Permanente, and a member of the NPSF board of directors.

"We've renamed the process RCA2—RCA squared—with the second A meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone's time," said Dr Bagian. "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."

RCA is commonly conducted after harm occurs. The NPSF guidelines emphasize the need to prioritize hazards based on the risk they pose, even if harm has not occurred. Prioritizing hazards according to risk is consistent with the practice of other high-reliability industries, such as aviation.

"This report underscores the responsibility of leaders in affecting change by providing clarity around their role in the RCA2 process while also providing recommendations that will better ensure the patient perspective is heard," said Bonacum.

National Patient Safety Foundation, NPSF, Tejal Gandhi, US