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PSNet: Patient Safety Network
Journal Article

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26(5):381-387.

Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.