PS 201 Lesson 1: Preparing for Root Cause Analyses and Actions
Accidents in health care almost never stem from a single cause. Usually, a host of contributory factors cause an adverse event to happen. This lesson introduces a systems-level response to adverse events and near misses called Root Cause Analyses and Actions (RCA2).
Estimated Time of Completion: 30 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Explain how adverse events and near misses can be used as learning opportunities.
2. Describe the key elements of the Root Cause Analyses and Actions (RCA Squared) process.
3. Explain the concept of risk-based prioritization.
4. Describe several tools to support the process 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.