ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses
- 11 May 2010
- journal article
- other
- Published by Ovid Technologies (Wolters Kluwer Health) in American Journal of Medical Quality
- Vol. 25 (3), 186-191
- https://doi.org/10.1177/1062860609359533
Abstract
The root cause analysis (RCA) process is used to investigate adverse events. However, it may not reduce the risk of recurrence as effectively as intended. The authors propose adapting a risk prioritization and reduction process modeled after the Commercial Aviation Safety Team (CAST). The process involves the following: (a) increasing effectiveness of selected interventions by prioritizing each cause/contributing factor based on its role in the current sentinel event as well as in future events; interventions are then selected based on their ability to remediate the root causes/contributing factors and the likelihood of successful implementation; (b) measuring effectiveness of intervention implementation; and ( c) evaluating effectiveness of the interventions by measuring the rates of event recurrence, near misses, contributing factors, mitigating factors, and staff perceptions of risk. Teams that evaluate intervention effectiveness are independent of those that implement the intervention. This framework seeks to improve the RCA process and provide further insights into advancing patient safety.Keywords
This publication has 8 references indexed in Scilit:
- The Effectiveness of Root Cause Analysis: What Does the Literature Tell Us?The Joint Commission Journal on Quality and Patient Safety, 2008
- Effectiveness and Efficiency of Root Cause Analysis in MedicineJAMA, 2008
- Work system design for patient safety: the SEIPS modelMaterials, 2006
- Tracking Progress in Patient SafetyJAMA, 2006
- Using Root Cause Analysis to Improve Survival in a Liver Transplant Program1Journal of Surgical Research, 2005
- Decreasing Mortality for Patients Undergoing Hip Fracture Repair SurgeryThe Joint Commission Journal on Quality and Patient Safety, 2005
- Using Aggregate Root Cause Analysis to Improve Patient SafetyThe Joint Commission Journal on Quality and Safety, 2003
- The role of safety analysis in accident preventionAccident Analysis & Prevention, 1988