ABSTRACT
The goal of healthcare RCA is to eliminate potential patient harm through the elimination of repeat unintended events. This chapter explores using trending and other strategies for preventing Repeat Events and for progressing toward zero harm.
It is important to define what is meant by a Repeat Event. A definition of a Repeat Event is presented as, “A repeat occurrence of harm with the same specific facts of the Mode and the same Latent Root causes.” If a Repeat Event is confirmed, the strategies for preventing future reoccurrences vary. This chapter addresses how to spread the RCA action plans beyond the local department or unit where an event occurred and proactively implement the improvement to prevent the same event from reoccurring elsewhere. A matrix of appropriate strategies for each circumstance of Repeat Events is provided.
Prioritizing and monitoring progress toward this goal requires tracking and trending at the Event, Mode, and Latent Root levels. Recommended metrics for each level are provided.
