According to new guidelines released this week by the National Patient Safety Foundation health care organizations should both understand why a medical error happened and take strong action through its root cause analysis process to keep it from happening again.

Root cause analysis is the term or the investigative process widely used by health professionals to learn how and why medical errors, adverse events and near misses occur, with emphasis on implementing and assessing actions to measure their success in preventing or reducing patient harm.

The National Patient Safety Foundation has renamed the process to root cause analysis action (RCA2). The reason for the addition of action is because unless real actions are taken to improve things, the root cause analysis is effort is essentially a waste of everyone’s time.

A big goal of the project is to help root cause analysis teams learn to identify and implement sustainable, systems-based actions to improve the safety of care.

Healthcare organizations can download the new guidelines found in the report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. The National Patient Safety Foundation will discuss the guidelines during and open webcast scheduled for Wednesday, July 15.

The foundation intends for the guidelines to help healthcare organizations improve the way they investigate medical errors. Some of the recommendations include the active involvement of leadership, such as the CEO and board of directors, in the RCA2 process.

The guidelines additional urge leaders to improve and periodically review the status if actions that result, understand what a thorough RCA2 report should include and act when reviews do not meet those requirements and review the RCA2 process for effectiveness at least once a year.

Millions of patients in the United States fall victim annually as a result of healthcare mistakes. If 2013 research is correct, hospital medical errors are now the third leading cause of death in the United States. 


Gerry Oginski
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NY Medical Malpractice & Personal Injury Trial Lawyer
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