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.