BC Patient Safety & Quality Council

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Quality Café: The 60-Minute Root Cause Analysis

This Quality Café serves as a live demonstration of the 60-Minute Root Cause Analysis (RCA). The 60-Minute RCA is an interactive workshop that uses local cases and incident reports to examine system breakdowns leading to medical errors, near misses, or adverse events with front line providers. The workshop is directed by a facilitator with a background in quality improvement and patient safety (QIPS). The audience is a group of front line providers bringing practical knowledge to develop improvements to effect change. No QIPS experience is expected or necessary for participation. The workshop will cover the following:

  • the AHRQ definitions of medical errors, near misses, and adverse events
  • a process map of an adverse event
  • constructing an Ishikawa or fishbone diagram to understand the multifaceted causes of an error
  • an introduction to hierarchy of interventions
  • developing and plotting interventions on an impact/effort matrix

After seeing this demonstration, you will be able to adopt and adapt the 60-Minute RCA process for use on your own cases.

Presenters:

Matthew Ronan
Hospitalist, VA Boston Healthcare System

Lakshman Swamy
Pulmonary Critical Care Fellow & Chief Medical Resident, Boston Medical Center

Resources:

Click to download the slides from this Quality Café.

Watch the recording:

Program: BCPSQC