National Patient Safety Foundation Issues Guidelines on Root Cause Analysis

Recommendations To Be Discussed During Open Webcast July 15


BOSTON, June 16, 2015 (GLOBE NEWSWIRE) -- The National Patient Safety Foundation (NPSF), a central voice for patient safety since 1997, today released guidelines developed to help health care organizations improve the way they investigate medical errors, adverse events, and near misses. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm has been endorsed by a number of related organizations and is being widely distributed to hospitals, health systems, and other settings.

Millions of patients in the United States are harmed every year as a result of the health care they receive. Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With a grant from The Doctors Company Foundation, NPSF convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process.

"NPSF heard from many health professionals about the need for best practices around RCA," said Tejal K. Gandhi, MD, MPH, CPPS, president and chief executive officer, NPSF. "We wanted to help those in the field improve their processes with a standardized approach and with the ultimate goal of preventing harm."

James P. Bagian, MD, PE, a member of the NPSF Board of Governors and director of the Center for Health Engineering and Patient Safety at the University of Michigan, served as co-chair of the expert panel along with Doug Bonacum, CSP, CPPS, vice president, Quality, Safety, and Resource Management, Kaiser Permanente, and a member of the NPSF Board of Directors.

"We've renamed the process RCA2—RCA squared—with the second A meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone's time," said Dr. Bagian. "A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care."

RCA is commonly conducted after harm occurs. The NPSF guidelines emphasize the need to prioritize hazards based on the risk they pose, even if harm has not occurred. Prioritizing hazards according to risk is consistent with the practice of other high-reliability industries, such as aviation.

"This report underscores the responsibility of leaders in affecting change by providing clarity around their role in the RCA2 process while also providing recommendations that will better ensure the patient perspective is heard," said Mr. Bonacum.

Dr. Bagian and Mr. Bonacum will discuss the new guidelines during an open webcast scheduled for Wednesday, July 15, at 1:00 PM Eastern Daylight Time. Registration is free of charge.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm may be downloaded from the NPSF website at

The following organizations have endorsed the use of these guidelines as a valuable resource in efforts to create a more effective event analysis and improvement system:


AAMI Foundation

Association of Occupational Health Professionals in Health Care (AOHP)

Aurora Health Care

Canadian Patient Safety Institute

Children's Health Queensland Hospital and Health Service


Citizens for Patient Safety

CRICO | Risk Management Foundation of the Harvard Medical Institutions

The Doctors Company

ECRI Institute

HCA Patient Safety Organization, LLC

Institute for Healthcare Improvement

Institute for Safe Medication Practices

The Joint CommissionKaiser Permanente

MHA Keystone Center

National Association for Healthcare Quality (NAHQ)

About the National Patient Safety Foundation

The National Patient Safety Foundation's vision is to create a world where patients and those who care for them are free from harm. A central voice for patient safety since 1997, NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and disseminate strategies to prevent harm. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the Foundation's work, visit and follow @theNPSF on twitter.

About The Doctors Company Foundation

Created in 2008 by the largest national insurer of medical liability for physicians, surgeons and other health professionals, the Doctors Company Foundation provides charitable grants to support patient safety research, forums and pilot programs, patient safety education programs and medical liability research. Learn more at


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