Root Cause Analysis (RCA) & Quality Improvement (QI) Processes

"Many…errors are picked up by the patient or another health care professional before the drug is administered, but even if the patient takes the drug, most such incidents do not lead to harm. Nonetheless, the errors signal vulnerabilities in the system and provide valuable learning opportunities for the prevention of similar mishaps that could result in harm. Simply 'being more careful' is usually not a solution, as most of the causes of error are related to system factors. ‘Accidents’ typically result from a sequence of events that tend to follow recurrent patterns, regardless of the personnel involved. All staff, even the most experienced and dedicated professionals, may be involved in preventable adverse events.” *
* Using Root Cause Analysis to Determine System-Based Causes of Error, CPJ/RPC, May/June 2006, www.ismp-canada.org/download/CPJ2006MayJun.pdf

RCA & QI General Resources (click here)

RCA & QI Links:

• Baylor University Medical Center, Techniques for Root Cause Analysis
• MedQIC, Quality Improvement Methods
• US Department of Veterans Affairs, National Center for Patient Safety, Root Cause Analysis
• US Department of Veterans Affairs, National Center for Patient Safety, Root Cause Anaylsis Tools