National Patient Safety Foundation Issues New Root Cause Analysis Guidelines

By Lea Radick

The National Patient Safety Foundation recently released guidelines to help health professionals standardize their use of root cause analysis and renamed the process “RCA2” to emphasize the fact that preventing harm requires both analysis and action to be taken. The guidelines offer nine recommendations for hospitals and systems:

  • Leadership, e.g., the CEO and board of directors, should be actively involved in the RCA2 process;
  • Leadership should review the RCA2 process at least annually for effectiveness;
  • Blameworthy events that are not appropriate for RCA2 review should be defined;
  • Facilities should use a risk-based approach to prioritize safety events, hazards and vulnerabilities;
  • RCA2 reviews should be started within 72 hours of recognizing that a review is needed;
  • RCA2 teams should be composed of 4 to 6 people unrelated to the event, including subject matter experts, a leader who is knowledgeable in safety science and a patient representative;
  • Time should be provided during normal work hours for staff to serve on an RCA2 team;
  • RCA2 tools, including interview techniques, flow diagramming and others, should be used to facilitate the investigation and develop the strongest appropriate actions;
  • Feedback should be provided to all staff involved in the event, as well as to patients and/or their family members regarding the findings of the RCA2 process.

The NPSF report, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm,” aims to “ensure that efforts undertaken in performing RCA2 will result in the identification and implementation of sustainably systems-based improvements that make patient care safer in settings across the continuum of care,” according to the report executive summary.

The NPSF is holding a webcast July 15 to discuss the guidelines.