National Patient Safety Foundation Issues Guidelines on Root Cause Analysis

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The National Patient Safety Foundation (NPSF) recently released guidelines developed to help health care organizations improve the way they investigate medical errors, adverse events, and near misses. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is available for download on the Foundation’s website at

Millions of patients in the United States are harmed every year as a result of the health care they receive. Root cause analysis (RCA) is widely used by health professionals to learn how and why errors occurred, but there have been inconsistencies in the success of these initiatives. With a grant from the Doctors Company Foundation, NPSF convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process.

“NPSF heard from many health professionals about the need for best practices around RCA,” said Tejal K. Gandhi, MD, MPH, CPPS, president and chief executive officer, NPSF. “We wanted to help those in the field improve their processes with a standardized approach and with the ultimate goal of preventing harm.”

The new guidelines specifically add the word “actions,” to indicate how important it is to put changes in place to avoid recurrence of a safety lapse.

Among the recommendations:

  • Use a risk-based approach (rather than a harm-based approach) to prioritize safety events, hazards and vulnerabilities.
  • Take care in forming RCA teams to include subject matter experts, as well as staff who are naïve to the subject or area under review, a leader with strong knowledge of safety science and the practice of RCA, and a patient representative.
  • Use interviewing techniques, action hierarchy, and other tools to facilitate the investigation and develop the strongest appropriate actions.

The content of the new report is the topic of an open webcast scheduled for July 15. Registration is free of charge.