1. Home
  2. Analyze

Root Cause Analyses and Actions – RCA²

How your organization responds after an adverse event is critical to patient safety. Done well, a root cause analysis — commonly referred to as an RCA — is a key step on the path to improving patient safety practices in your organization. Unless you probe the underlying causes of a patient harm event or "near miss," you won't know exactly WHAT happened, WHY it happened, and HOW to prevent it from happening again.

Conduct an RCA²

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.

ASAP
I
Before you start
  • Stabilize the situation
  • Decide if RCA² is best for analyzing the event or risk
  • Involve the facility's leadership
Within 30 days
II
The analytic work
  • Determine what happened
  • Develop causal statements
  • Identify solutions and corrective actions
Timeframe will vary
III
From analyses to actions
  • Implement action plans
  • Measure progress
  • Offer feedback


Adapted from the National Patient Safety Foundation's 2016 Report: RCA2 Improving Root Cause Analyses and Actions to Prevent Harm

Download the full report here
The Patient Safety Navigator is provided by the Betsy Lehman Center for informational purposes. You cannot submit adverse event reports or other data through the Navigator. Your use of the Navigator will not be monitored, and no data will be collected beyond what is explicitly noted in the Website Privacy Statement. Although the Betsy Lehman Center intends to maintain the Navigator’s contents, we cannot guarantee that the information will be accurate, complete, or up-to-date at all times. You should be aware that regulations and reporting systems are subject to change without our knowledge or could be interpreted differently by the agencies that oversee them. By using the Navigator, you agree that you are solely responsible for determining any reporting obligations applicable to you or your organization. For further terms and conditions, see the Terms of Use.
©2024, Betsy Lehman Center
Privacy Statement | Feedback