How root-cause analysis can improve patient safety.

A key to improving patient safety and providing quality care is identifying, reporting, reviewing, and addressing the problems that are related to adverse events and close calls. A tool that has evolved to meet this need is the use of root-cause analysis (RCA). But can more be done with the RCA to make it work smoothly within a health care setting--while providing useful information in a timely manner that health care organizations can act upon? Staff at the Department of Veterans Affairs involved with patient safety think so. Last month, they discussed numerous initiatives--ranging from "triage cards" to redesigned software applications to redefined leadership roles--that are giving a new edge to using RCA effectively throughout the 170-plus VA health care facilities across the country.