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  2. Root Cause Analysis and Medical Error Prevention

    www.ncbi.nlm.nih.gov/books/NBK570638

    Upon completing this activity, healthcare professionals will gain a comprehensive understanding that root cause analysis (RCA) is a mandated process for healthcare institutions to mitigate future errors and promote patient safety.

  3. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

    www.ihi.org/resources/tools/rca2-improving-root...

    This tool describes best practices for conducting a comprehensive Root Cause Analyses and Actions (RCA2) to improve patient safety by reducing medical errors, adverse events, and near misses; the Action Hierarchy tool helps identify which specific actions will have the strongest effect for successful and sustained system improvement.

  4. Root Cause Analysis - PSNet

    psnet.ahrq.gov/primer/root-cause-analysis

    Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care.

  5. Strategies and Approaches for Investigating Patient Safety ...

    psnet.ahrq.gov/primer/strategies-and-approaches...

    Root cause analyses (RCAs) are problem-solving tools and techniques used to retrospectively discover causes of patient safety adverse events and near misses. Root causes are core issues that directly lead to the safety issue.

  6. Root Cause Analysis in Health Care: A Joint ... - PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-health...

    This revised publication provides information about updated approaches to root cause analysis with an emphasis on identification of causal and contributing factors. It highlights the use of failure mode and effects analysis as a complementary sentinel event examination strategy that enables design of proactive and reactive improvements.

  7. Guide to Performing a Root Cause Analysis (Revision 02/05/2021)

    www.patientsafety.va.gov/docs/RCA-Guidebook...

    Patient safety events can cause serious harm or death. To address and prevent these threats, health care organizations must unearth the root causes and develop solutions that address the problems from a systems perspective. Despite advances in health care, the occurrence of failures persists. When failures reach the patient, the results

  8. How Much of Root Cause Analysis Translates into Improved ...

    pmc.ncbi.nlm.nih.gov/articles/PMC7768139

    Root cause analysis (RCA) emerged in the health care field almost 20 years ago. This technique is used worldwide to understand the remote and direct factors favouring the occurrence of an avoidable adverse event (AAE) [1], and improvement of patient safety [2].