Now it's time for your organization to take the recommendations from your rich analytic work and implement them to improve the underlying care systems to better ensure patient safety.
A responsible individual with the authority to act, not a team or committee, should be responsible for ensuring implementation of all the corrective actions. It is not ideal to have multiple individuals or a committee assigned this responsibility because it can dilute accountability and undermine the probability of successful implementation.
For the RCA² process to be successful, it is critical that it be supported by all levels of the organization including the chief executive officer and board of directions. Each action recommended by a review team should be approved or disapproved, preferably by the CEO. If an action is disapproved, the reason for its disapproval should be documented and shared with the RCA² team so that the constraint preventing implementation can be understood and an alternative action developed by the team.
In addition, present the team's work to leadership of the service/department, staff involved, patient and/or patient’s family, the organization, and the patient safety organization (if relevant). Feedback to the organization as a whole helps build or reinforce a culture of safety and reporting, permitting staff to see the improvements that result from these reports.