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Root Cause Analysis (or “RCA”)

Root Cause Analysis (or “RCA”). RCA is a systematic process that seeks to explore all of the possible factors associated with an incident by asking: what happened why it happened what can be done to prevent it from happening again.

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Root Cause Analysis (or “RCA”)

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  1. Root Cause Analysis (or “RCA”) • RCA is a systematicprocess that seeks to explore all of the possible factors associated with an incident by asking: • what happened • why it happened • what can be done to prevent it from happening again Source: http://www.who.int/patientsafety/education/curriculum/course5a_handout.pdf From: World Health Organization. Downloaded on Jan 31 2014

  2. How Does an RCA Work at Penn? • RCAs typically occur within 1-2 weeks of the event • We invite/include all staff involved in the patients’ care • The discussion is facilitated by a patient safety officer or director • There is a focus on a Blame-free environment; “safe zone” Changes to systems & processes ~ 10,000 PSNs/year ~ 60-80 RCAs/year Event & Changes brought to M&M

  3. You May Receive an Email Invitation to an RCA at Penn • If so….don’t panic or feel anxious, it is a normal part of the way we solve problems at Penn • Housestaff are invited to these discussions regularly • Ask your chief or program director if they can assist you in attending the meeting if you are struggling with clinical duties at the same time • No preparation is necessary for the meeting. However you can call the phone number in the email to find out which case the discussion is going to be about in order to review the case records prior to the meeting if you wish.

  4. A Video is Worth a Thousand Words • What is a root cause analysis discussion like? • Have other residents and fellows like me experienced an RCA. What do they think? • I have heard other people talk about RCAs, but I am not sure if what I hear is true. http://www.uphs.upenn.edu/employeeselfservice/pma/prettyphoto/rca-video.html

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