In this pilot project, a multidisciplinary team convened to enhance root cause analysis practices to take more effective, systems-based actions to ensure patient safety. By using cognitive aids and building RCA best practices into technological platforms, staff was able to identify and select causal factors beyond human factors with greater than 85% efficiency. Because of the resource challenges in correctional health care, technology systems can be an important element in hardwiring quality improvement.

Educational Objectives:

Identify common root cause types for events in health care

List relevant causal factors for most common root cause types

Differentiate between intermediate and stronger, more sustainable actions

Level: Intermediate