RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
This tool describes best practices for conducting a comprehensive Root Cause Analyses and Actions (RCA2) to improve patient safety by reducing medical errors, adverse events, and near misses; the Action Hierarchy tool helps identify which specific actions will have the strongest effect for successful and sustained system improvement.
Highlights
- Root Cause Analyses and Actions (RCA2) event review process
- Action Hierarchy tool instructions, example, and template
Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives.
To identify best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses, we have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so we have renamed the process Root Cause Analyses and Actions, or RCA2 (RCA “squared”) to emphasize this point.
The purpose of RCA2 is to identify and implement sustainable systems-based improvements that make patient care safer in settings across the continuum of care. The approach is two-pronged:
- Identify methodologies and techniques that will lead to more effective and efficient RCA2
- Provide tools to evaluate individual RCA2 reviews so that significant flaws can be identified and remediated to achieve the ultimate objective of improving patient safety
The intent of an RCA2 review is to identify system vulnerabilities so that they can be eliminated or mitigated; the review is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues.
After completing the RCA2 investigation and analysis process, RCA2 teams work to identify corrective actions to mitigate root causes of the adverse event. A tool such as the Action Hierarchy will assist clinical teams in identifying which actions will have the strongest effect for successful and sustained system improvement.
*NOTES:
- Before filling out the templates, first save the PDF files to your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.
- IHI does not endorse any software or training for the RCA2 process that is not directly provided by IHI.
How to Cite These Documents:
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston: National Patient Safety Foundation; 2015.
Patient Safety Essentials Toolkit: Action Hierarchy Tool. Boston: Institute for Healthcare Improvement; 2019. (Available at ihi.org)
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