Sound familiar? It has been a very long year with the pandemic and working through one crisis after another right? It is truly time to get back to basics, let’s move the bar and take action on some of the things that we can truly change or improve! Root Cause Analysis has been around forever and a day, it assists us in determining the “why” something happened to hopefully prevent it from occurring again. Take a look at your storage rooms for example. Did you ever think that they would be stockpiled with PPE? Of course not, but did you ever think we would have a pandemic? Of course not! At a minimum, we did learn the cause of some of our angst, a lack of PPE, and most of us won’t allow that to happen again!

AHRQ Patient Safety Network has published a toolkit to assist in determining the cause of unusual, oftentimes negative outcome events. The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based improvements after the investigation of patient safety events. The “Human Factors Analysis and Classification System” (HFACS), the Human Factors Matric (HFIX), and a decision tool called FACES and describes how these tools can be integrated into the RCA2 framework to foster a comprehensive, human factors analysis of patient safety events and the identification of broader system interventions.

Take a look, enjoy the guidance as it is pretty interesting and timely! The tools are downloadable and available to you at no cost! Share with your QAPI committee and maybe find an area within your organization that you can improve on! Stay the course, stay well, mask up, get vaccinated and stay tuned!