ECRI Institute has endorsed new root-cause analysis (RCA) guidelines published by the National Patient Safety Foundation (NPSF) to help healthcare organizations improve the way that they investigate adverse events and near misses. Developed by a panel of subject matter experts convened by NPSF, including ECRI Institute's James P. Keller, Jr., MS, vice president, international market development, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm improves on the effectiveness of the traditional RCA process by adding the words "and action" and emphasizing that if actions derived from an RCA are not implemented and measured to validate their success in preventing or reducing the risk of patient harm, then the entire exercise will have been a waste of an organization's time and resources. Recommendations include using a risk-based approach (rather than a harm-based approach) to prioritize safety events, hazards, and vulnerabilities; forming RCA teams that include subject matter experts as well as staff who are naïve to the subject, a leader with strong knowledge of safety science and the practice of RCA, and a patient representative; and using interviewing techniques, flow diagramming, action hierarchy, and other tools to facilitate the investigation and develop the strongest appropriate actions. The guidelines will be discussed in a free July 15, 2015, webinar hosted by NPSF.

HRC Recommends: The work and resources spent on an investigation and RCA are wasted if deeper organizational issues are not unearthed from the investigation or if the actions taken as a result do not address them. Risk managers should review the NPSF guidelines on RCAs to identify possible opportunities to improve the process at their organizations. See "Resources" for additional guidance on RCAs from HRC.