COVID-19 Impact

You may see some delays in posting new content due to COVID-19. If you have any questions, please submit a message to PSNet Support.
 

PSNet: Patient Safety Network
Journal Article
Study

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 quality & safety. 2017;26:381-387.

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.