You have spent a lot of time and effort in conducting RCAs on incidents. Pause and ask yourself: How many formal action plans have you initiated and implemented? Are the control measures taken effective in improving patient safety? Why are similar incidents recurring after RCA has been conducted?
If your own experience on RCA reviews and the outcome are mixed, you are not alone. Various studies have shown that the RCA process has had inconsistent success. There are challenges and limitations in conducting RCAs in healthcare settings. Its potential has remained under-utilized in healthcare.
This Guide is intended for Patient Safety, Quality and Risk Managers. The goal is to help you identify and implement systems-based actions to improve patient safety and prevent harm.