ABSTRACT
RCA is not just a meeting; it is a rigorous, standardized process designed to lead to tangible results for preventing failures and improving safety. This chapter describes the immediate needs following an unintended event, which allows for the rapid onset of an early investigation. Early investigation preserves and collects the evidence, identifies immediate countermeasures required for safety, and provides support for affected caregivers. The interviewing skills required and steps to address the emotional state of involved caregivers are described to support acquiring and preserving information from the people involved.
The chapter further provides advice and tools for completing the tasks in preparation for an RCA team meeting, which are completed by the RCA facilitator in coordination with the Executive Sponsor and the Process Owner. These tasks include defining the Event, ordering the team, creating the Event chronology, documenting the Logic Tree Event and Mode, and managing the logistical needs for RCA team meetings. Scheduling RCA team meetings is one of the biggest challenges in RCA. Experience is shared of a successful scheduling strategy using standing RCA meetings, which avoids delays of weeks or months. The duration of these meetings for successful RCA is also discussed.
