PS 105 Lesson 4: Learning From Errors Through Root Cause Analysis
Accidents in health care almost never stem from a single cause. Usually, there is a host of contributory factors that cause an adverse event to happen. This lesson introduces a response to error, called root cause analysis (RCA), which seeks to identify and address the contributory factors that lead to patient harm. By the end, you’ll learn a step-by-step approach to improving the systems that cause adverse events and near misses.
Estimated Time of Completion: 25 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Explain the importance of seeking answers after adverse events and near misses.
2. Describe why it's more effective to look for systems problems after errors than to blame individuals.
3. List who should be on a root cause analysis team.
4. List five steps for conducting a root cause analysis.
Contributors
Author(s):
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, Senior Managing Editor, Institute for Healthcare Improvement View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health 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.