On June 16th, the National Patient Safety Foundation (NPSF) issued guidelines intended to improve the investigations of and responses to adverse events, near misses, and medical errors. The report, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm,” was written with input from professionals across the spectrums of health care and patient safety. Dr. Tejal Gandhi, president and chief executive officer of NPSF, said,

We wanted to help those in the field improve their processes with a standardized approach and with the ultimate goal of preventing harm.

The second ‘A' of RCA2 stands for action. As Dr. James Bagian notes, a major aim of this report is help providers “identify and implement sustainable, systems-based actions to improve the safety of care.” The new methodology expands the focal point of the root cause analysis process from identification of causal factors to a strategic, integrated, and standardized approach to responding to an adverse event or near miss. As Carol Keohane, MS, RN assistant vice president, Patient Safety at CRICO, a member of the subject-matter expert panel, states:

This is an important body of work that will help our organizations standardize the approach towards performing an RCA. Additionally, this tool will help organizations learn to identify the causative factors that contribute to safety events with a goal towards developing actionable improvement strategies to mitigate the risks associated with patient harm.”

NSPF will be hosting a free, open webcast on the RCA2 report on July 15th, 1:00PM Eastern Daylight Time. Those interested may register here.

Related Blog Posts

    1x1_auto_0106

    Telehealth Gone Wrong? Not After These Videos

    Blog Post
    Virtual visits can involve patients calling into their video appointment from the supermarket…fuzzy computer screens during examinations…even doctors “visiting” the wrong patient. These challenges and more present additional clinical and liability risks to busy practices delivering telehealth.
    1x1_auto_0011

    Best Practices for Employment Practices Liability Reporting

    Blog Post
    Reporting processes for complaints of unprofessional behavior vary across and within CRICO member organizations. This variability exposed an opportunity to identify practices that allow for a fair, prompt, consistent, and well-coordinated response to complaints of unprofessional behavior. Learn how you can manage wrongful acts in your workplace.
    1x1_auto_0068

    Structured Patient Handoffs Can Help Avoid Malpractice Cases

    Blog Post
    Using Candello data, researchers at Boston Children's Hospital demonstrated a link between patient handoff failures and malpractice cases. Further, they showed that, among cases involving a communication error, 77 percent of them could have been prevented by use of a structured handoff.
X
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.
Confirm