ABSTRACT
Without improvement work to prevent future reoccurrence of unintended events, the goal of RCA is not achieved. This chapter confronts one of the most frequent failures of healthcare RCA: the failure to implement effective action plans. It describes a novel approach for action planning, provides an action plan template and rigor test, identifies successful implementation tools, and discusses appropriate implementation metrics.
Experience shows that there are three main reasons that action plans are not fully implemented: (1) the sheer number of action items recommended; (2) the implementation difficulty for many of the action items; (3) the lack of a management system to track, or to identify barriers preventing, the completion of action plans. Each of these reasons must be addressed for successful elimination of latent root causes.
Unintended events occur when the multiple failures in systems align, and safeguards are penetrated. In a Logic Tree, Latent Roots function as Boolean AND operators: all are required for the Mode failure to occur. Eliminating any one of the Latent Roots will prevent the Mode from reoccurring. With this insight, the RCA team is guided to select the one Latent Root which in their determination can be most easily eliminated.
