AHRQ Patient Safety Network ► Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

AHRQ Patient Safety Network



Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its valueas a safety improvement strategy.

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