title: Root Cause Analysis: Learning from Adverse Safety Events.
abstract: Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential that radiologists, both as individuals and as a part of organizations, learn from such events and make appropriate changes to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a process to (a) identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and (b) allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future. An RCA process should be performed within the environment of a culture of safety, focusing on underlying system contributors and, in a confidential manner, taking into account the emotional effects on the staff involved. The Joint Commission now requires that a credible RCA be performed within 45 days for all sentinel or major adverse events, emphasizing the need for all radiologists to understand the processes with which an effective RCA can be performed. Several RCA-related tools that have been found to be useful in the radiology setting include the "five whys" approach to determine causation; cause-and-effect, or Ishikawa, diagrams; causal tree mapping; affinity diagrams; and Pareto charts.
authors.affiliation: From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (O.R.B., J.B.K., R.L.E.); and Department of Radiology, Stanford University, Stanford, Calif (D.B.L.).
authors.forename: Olga R
authors.initials: OR
authors.lastname: Brook
authors.affiliation: From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (O.R.B., J.B.K., R.L.E.); and Department of Radiology, Stanford University, Stanford, Calif (D.B.L.).
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Kruskal
authors.affiliation: From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (O.R.B., J.B.K., R.L.E.); and Department of Radiology, Stanford University, Stanford, Calif (D.B.L.).
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Eisenberg
authors.affiliation: From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (O.R.B., J.B.K., R.L.E.); and Department of Radiology, Stanford University, Stanford, Calif (D.B.L.).
authors.forename: David B
authors.initials: DB
authors.lastname: Larson
mesh_terms: D000056:Accident Prevention; D015984:Causality; D006801:Humans; D033183:Interdisciplinary Communication; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control; D011871:Radiology / Q000458:organization & administration*; D012308:Risk Management / Q000592:standards; D060891:Root Cause Analysis; D017751:Safety Management; D012657:Self-Help Groups