National Patient Safety Foundation releases new guidelines for investigating medical errors

In addition to understanding why a medical error happened, healthcare organizations must also take strong action through its root cause analysis (RCA) process to keep it from happening again, according to new guidelines released this week by the National Patient Safety Foundation (NPSF).

In fact, the NPSF has renamed RCA--the term for the investigative process widely used by health professionals to learn how and why medical errors, adverse events, and near misses occur, with emphasis on implementing and assessing actions to measure their success in preventing or reducing patient harm.

"We've renamed the process RCA2--RCA squared--with the second 'A' meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone's time," says James P. Bagian, M.D., who co-chaired the panel to develop the guidelines. "A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care." 

Healthcare organizations can download the new guidelines found in the report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. The NPSF will discuss the guidelines during an open webcast scheduled for Wednesday, July 15.

The foundation intends for the guidelines to help healthcare organizations improve the way they investigate medical errors. Recommendations include the active involvement of leadership, such as the CEO and board of directors, in the RCA2 process. The guidelines urge leaders to:

  • Approve the investigation process
  • Approve and periodically review the status of actions that result
  • Understand what a thorough RCA2 report should include and act when reviews do not meet those requirements
  • Review the RCA2 process for effectiveness at least once a year

Millions of patients in the United States are harmed each year as a result of healthcare mistakes, according to the NPSF. In fact, if 2013 research is correct, hospital medical errors are now the third leading cause of death in the United States. Not even the most prestigious healthcare organizations are immune to medical errors. For instance, researchers at the Mayo Clinic found 'never event' surgical errors happen at their campus at a rate of 1 in 22,000 procedures.

While root cause analysis is widely used, improvement initiatives have had mixed results, according to the NPSF. With a grant from The Doctors Company Foundation, NPSF convened a panel of experts and stakeholders to examine best practices and develop guidelines to standardize the process.

Healthcare organizations commonly conduct a root cause analysis after harm occurs. The NPSF guidelines emphasize the need to prioritize hazards based on the risk they pose, even if harm has not occurred. Prioritizing hazards according to risk is consistent with the practice of other high-reliability industries, such as aviation, it says.

 To learn more:
- read the NSPF article
- download the guidelines

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