When a serious patient safety event occurs, the health care organization must identify and examine the system failures or defects that contributed to the event to guard against future reoccurrences. Root cause analysis (RCA) provides a systematic approach to identify these contributing factors. In the specific case of a sentinel event, The Joint Commission requires accredited organizations to perform a comprehensive systematic analysis. However, RCA also can be used as a proactive tool to identify potential safety problems before they reach a patient. This book includes examples that guide the reader through application of root cause analysis to the investigation of specific types of sentinel events, such as medication errors, suicide, treatment delay, and elopement.
Root Cause Analysis in Health Care: Tools and Techniques, 6th edition, provides updated statistics and introduces new concepts and tools associated with RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, the National Patient Safety Foundation’s in-depth report focusing on the techniques and processes of how root cause analyses can best prioritize system flaws and vulnerabilities and make improvements to successfully improve patient care in all health care settings. This book also includes new and revised tools aligned with the Joint Commission’s Robust Process Improvement® (RPI®), a set of process improvement strategies adopted by The Joint Commission to help organizations improve business processes and clinical outcomes.