We partnered with the National Patient Safety Foundation (now part of the Institute for Healthcare Improvement) to adapt its guide to root cause analysis for your use. It's called RCA-squared to emphasize that the work doesn't end with analysis. The second "A" is for "Action." Once you understand the cause of an event, it's time to work collaboratively to develop and implement an action plan to prevent future harm. Start by clicking on Step I below.
Adapted from the National Patient Safety Foundation's 2016 Report: RCA2 Improving Root Cause Analyses and Actions to Prevent Harm