RCA^2 Recommendations
Leadership should review the RCA^2 process at least this frequently
What is annually?
Interviewing techniques, 5 rules of causation, Flow and Cause and Effect Diagramming are examples of
What are RCA^2 tools?
Events that are a result of criminal acts, patient abuse, deliberately unsafe or related to substance abuse of care team member
What are blameworthy events?
RCA^2 recommends that these types of events should be defined as whether they are appropriate for review
What are blameworthy events?
When expertise is needed and not represented by members attending the RCA^2 meeting this tool is used to gain the necessary information
What is interviewing?
Being mindful of organizations resources it is essential to have this type of prioritization to credibly and efficiently identify what hazards need to be addressed
What is risk-based prioritization of events?
Transparent, formal and explicit describe these types of systems used to identify adverse events, close calls, and system vulnerabilities
What are risk based prioritization?
RCA^2 recommends that the RCA team be this number of attendees
What is 4-6 members?
In a addition to harm events these types of events should be prioritized using the risk matrix
What are near miss events?
Once recognized as necessary an RCA^2 review should begin within this time frame
What is 72 hours?
An understanding of how people can be set up to fail by improperly designed systems, equipment, devices, products and processes
What are human factors?
This type of review analyzes similar events
What is an aggregated review or common cause analysis?
Feedback from RCA^2 findings should be shared with
Who are staff involved in the event, patients and their family members?
This tool is a way to graphically describe the event in a chronological format
What is a flow diagram or timeline?
This is the most amazing group of Quality and Patient Safety professionals in the entire universe
Who are we?