Root cause analysis (RCA) is a common tool used by hospitals and anesthesia quality managers to learn from serious adverse events and near-misses. In this article, the Anesthesia Quality Institute (AQI) has invited some experts in this area to use a pro/con format to describe RCA methodology and examine some of its strengths and weaknesses. We’ll begin with the purpose and goals of an RCA.
Health care, especially hospital-based, is a highly complex integration of multiple providers performing high-risk procedures and administering potentially harmful medications to patients with significant underlying disease. It is not surprising, then, that some patients are harmed by the very health care that is intended to help them. A large study performed by the Office of the Inspector General found that approximately one in seven Medicare patients is harmed during his or her hospital stay, with about 50 percent of these cases deemed as potentially preventable....
