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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.



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