MHS Patient Safety Professionals:
Root cause analysis (RCA) is a systematic process used to study and learn from adverse events and unsafe conditions to identify actions that will prevent recurrence. Conducting an RCA empowers health care professionals to:
--Understand what happened
--Understand why it happened
--Take positive action to prevent it from happening again.
The majority of safety events are the result of faulty systems, processes and unsafe conditions that lead health care professionals to make mistakes or fail to prevent them. When conducting RCA's, it is important to maintain a systems-approach and avoid assignment of individual blame.
RCAs are a critical component of creating an enterprise-wide standard for improvement patient safety by allowing the MHS to learn from failure, correct deficiencies and prevent future harm.
DoD policy requires MTFs to actively identify all sentinel events (SEs), conduct RCAs, establish corrective action plans, report results and comply with The Joint Commission reporting requirements. More information on how to conduct an RCA is available in the PSP’s RCA Resource Guide. Please reference Appendix 1.1 in the RCA Resource Guide for the DoD’s RCA policy: https://go.usa.gov/xXcTS
Patient Safety Awareness Week News:
Stay tuned to see how Patient Safety Awareness Week was celebrated across the Military Health System. We’ll be showcasing details on the PSP web site next week!
If you haven’t already, please share what you did for Patient Safety Awareness Week viaDHA.firstname.lastname@example.org.
If you have questions, please e-mail us at DHA.email@example.com.
DoD Patient Safety Program Team