Patient Safety Update: Root Cause Analysis in Health Care: A PSNet PrimerAgency for Healthcare Research and Quality (AHRQ) sent this bulletin at 07/26/2013 11:42 AM EDT
Root cause analysis (RCA) is a widely-used, structured method to analyze errors in health care from a systems approach and eliminate the underlying causes that lead to patient harm. AHRQ’s Patient Safety Network (PSNet) offers a primer to guide health care providers and leaders through RCA as a key concept in patient safety, with background and contextual information, highlighting relevant materials to support RCA in the health care environment. The Joint Commission has mandated the use of RCA to analyze sentinel events (such as wrong-site surgery) since 1997, and many states require that RCA be performed and reported after a serious event.
To access the full patient safety primer, titled Root Cause Analysis, go to: http://psnet.ahrq.gov/primer.aspx?primerID=10.