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Tuesday 2:57 CST, January 16, 2018


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Quality and safety

June 17, 2015

National Patient Safety Foundation releases guidelines on root cause analysis


The National Patient Safety Foundation released guidelines Tuesday, June 16, to help health care organizations investigate medical errors, adverse events and near misses. Millions of patients in the United States are harmed every year as a result of the health care they receive. In response, NPSF examined best practices around root cause analyses to create the guidelines — titled RCA2: Improving Root Cause Analyses and Actions to Prevent Harm — and determine why those errors occurred. The focus of the guidelines is to prioritize hazards based on the risk each poses to the patient.

“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. James P. Bagian, MD, PE, a member of the NPSF board of governors and director of the Center for Health Engineering and Patient Safety at the University of Michigan. “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.”

A grant from the Doctors Company Foundation allowed NPSF to convene a panel of subject matter and stakeholders to examine best practices around RCAs, as well as design the guidelines to help health professionals standardize the process. Dr. Ronald M. Wyatt, MD, MHA, medical director in the division of health care improvement at The Joint Commission, was part of the panel’s expert advisory group. The guidelines are to be discussed during a free webcast Wednesday, July 15, at 10 a.m. PT | 11 a.m. MT | noon CT | 1 p.m. ET. Register.

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