Archive for the ‘ismp’ Category

RCA on Root Cause Analysis

In Force function, ismp, Root cause analysis on March 2, 2013 at 11:55 pm

flowerRCA (root cause analysis) is a tool often used to provide an assessment after the occurrence of an adverse event or when investigating the safety of an environment. The idea behind this risk assessment is to uncover the overt and latent factors behind unsafe situations.  In non-medical industries this has proven to be an effective tool but in healthcare, the belief that this tool helps is variable. While many RCAs have uncovered surprising holes in healthcare safety systems, there are also concerns with its value.

In a 2008 interview with Robert Watcher, Albert Wu  said “Although we are living in an era of evidence-based medicine, root cause analysis was widely adopted by the medical community in the 1990s without the benefit of much evidence. Every institution now conducts root cause analysis. Thousands of health care workers devote many hours to conducting these analyses, yet root cause analysis has never really been evaluated.” (AHRQ,

Some of the barriers to conducting root cause analysis:
(read the rest of this post) Read the rest of this entry »

%d bloggers like this: