The National Patient Safety Foundation offers recommendations to improve root cause analysis, emphasizing need for sustainable system improvements.Boston, MA: National Patient Safety Foundation; 2015.
RCA²: Improving Root Cause Analyses and Actions to Prevent Harm.
Boston, MA: National Patient Safety Foundation; 2015.
The National Patient Safety Foundation issued these guidelines for improving root cause analyses (RCAs) in health care organizations. RCAs are mandated by The Joint Commission following sentinel events and many states require them after reports of serious events. A panel of experts and stakeholders created these guidelines, which emphasize the importance of actions taken in response to RCA reviews to prevent future harms. They have proposed renaming the process root cause analysis and action (RCA²) to ensure that efforts will result in the implementation of sustainable systems-based improvements. The document provides strategies for applying efficient and effective RCAs, and it includes tools for evaluating RCA reviews. A prior AHRQ WebM&M perspective examined the application of RCAs for patient safety.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital.
Mathukia C, Fan W, Vadyak K, Biege C, Krishnamurthy M. J Community Hosp Intern Med Perspect. 2015;5:26716.
The rise of the medical scribe industry: implications for the advancement of electronic health records.
Gellert GA, Ramirez R, Webster SL. JAMA. 2015;313:1315-1316.
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Clinician support: five years of lessons learned.
Hirschinger LE, Scott SD, Hahn-Cover K. Patient Saf Qual Heathc. April 2015;12:26-31.