Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture.
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture. J Healthc Risk Manag. 2024;Epub Dec 20. doi:10.1002/jhrm.21587.
Root cause analysis (RCA) is a common strategy to investigate patient safety events but has been criticized for lack of action and a focus on the individual instead of the system. This article describes the implementation of a root cause analysis and action (RCA2) framework in a community health system. Key aims included building a multidisciplinary team, standardizing event communication, expanding support to affected staff, and decreasing time from event to action implementation.