Root cause analysis of SREs in Massachusetts

If you are a hospital or ambulatory surgery center, you are required to include a root cause analysis of a Serious Reportable Event (SRE) that occurred in your facility in a follow-up report to the Department of Public Health. We hope you find this RCA² material helpful as you prepare your report.

Remember, at a minimum, the 30-day report must include the following information:

• Any updates to the incident narrative since you filed your 7-day report;
• Analysis and identification of the root cause(s);
• Analysis of the event’s preventability, including answers to these three questions:
  • Was it preventable?
  • Was it within your facility’s control?
  • Was it unambiguously the result of a system failure?
• A description of any corrective measures taken following discovery of the SRE.

When filing electronically through the Virtual Gateway’s Health Care Facility Reporting System (HCFRS), information from your root cause analysis work will be entered in the free-text field labeled “Preventability Determination Narrative.”