ABSTRACT
Patients and their loved ones have the right to receive safe and harm-free care in healthcare settings. Unintended events that harm can have long-lasting and significant life impacts. When these events occur, patients and society expect us to learn and prevent the unintended vent from reoccurring. The most important reason for conducting RCAs in healthcare is to eliminate potential patient harm.
The power of RCA is in the depth of understanding gained in breaking down how an unintended event occurred and the steps required to prevent it from happening again. A thorough and rigorous RCA, as described in this book, finds the latent root causes of unintended events, cares for those impacted by the events by including them in designing improvements, and supports organizational learning as a key to creating a culture of safety.
The RCA approach described in this chapter allows individuals involved in or affected by an unintended event to gain the understanding of how the system failed and how they’re not the person to blame. It is one way in which a healthcare organization supports a shift from blaming caregivers to becoming a learning organization. A learning organization requires sharing the root causes discovered and the improvements made with their caregivers, medical staff leaders, senior executives, and boards.
