title: New practice guidelines aim to put teeth in the root cause analysis process .
abstract: While hospitals have been using root cause analysis (RCA) to identify the reasons for problems and errors for many years, experts note that the results of these efforts have been uneven at best. To improve the RCA process, a team of experts from the National Patient Safety Foundation (NPSF) have assembled best-practice guidelines to both standardize the RCA process and guide organizations in their improvement efforts. Further, they have renamed the process RCA squared or RCA2 to emphasize the need for action steps once an analysis is completed. Report authors say prioritization methods need to be devised so that near-misses and close calls receive more attention from RCA2 teams. RCA2 teams should be nimble, including four to six members, one of whom is a patient representative. When problems or errors emerge, the RCA2 process should commence within 72 hours, and the RCA2 team should complete its investigative work in 30 to 45 days. Experts say causal statements should outline what the solutions to a problem or error should be.
mesh_terms: D017408:Guidelines as Topic; D019300:Medical Errors / Q000517:prevention & control; D058996:Quality Improvement; D060891:Root Cause Analysis / Q000592:standards*