ABSTRACT
Many healthcare organizations have utilized some form of RCA for years yet continue to experience significant rates of patient harm. How can that be? Two possibilities exist: one is that the RCAs performed have not been successful, the other is that RCA as a tool is insufficient to reach zero harm. This chapter identifies the barriers to successful RCA and provides countermeasures and tools to increase the likelihood of success.
Three main hypotheses for how an RCA can fail are reviewed: (1) Latent Roots were not found, (2) Action Plans were not implemented, and (3) Action Plans were implemented but not effective. One role for RCA champions is to help facilitate the understanding of these possible sources of RCA failure and to advocate for countermeasures as part of the overall safety management system. Countermeasures discussed are RCA facilitation skills, Executive Sponsor roles, the organization’s culture of safety, and an RCA evaluation tool.
