PS 201 Lesson 2: Conducting Root Cause Analyses
This lesson describes how to conduct Root Cause Analyses and Actions (RCA2), focusing on actions that should occur within 45 days of an adverse event or near miss incident. You’ll learn whom to include on an RCA2 team, how to conduct interviews and draw a high-level flowchart to understand what happened, and how to use what you learn to develop causal statements.
Estimated Time of Completion: 25 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Identify who should included on a Root Cause Analyses and Actions (RCA Squared) team.
2. Apply strategies and tools to uncover root causes of events.
3. Describe successful practices to ensure optimal implementation of RCA Squared.
Contributors
Author(s):
James Bagian, Physician, University of Michigan Health System View Profile
Samuel Huber, MD, Associate CMO for Patient Safety and Quality, Rochester Regional Health System View Profile
Greg Ogrinc, MD, MS, Senior Associate Dean, White River Junction VA Medical Center View Profile
Editor(s):
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Joellen Huebner, Senior Project Manager, Institute for Healthcare Improvement View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Patricia McGaffigan, RN, MS, CPPS, Vice President, Safety Programs, Institute for Healthcare Improvement View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.