Root Cause Analysis in Healthcare: Strategies for Medical Error Prevention and Improvement-An Updated Review for Health Administrators

Abstract

Background: Medical errors are a significant concern in healthcare, resulting in preventable harm and substantial financial burden. These errors contribute to over 200,000 deaths annually in the United States and are linked to systemic shortcomings and poor healthcare processes. Root Cause Analysis (RCA) is recognized as a valuable tool in identifying the underlying causes of medical errors, particularly sentinel events, and implementing effective strategies for prevention.

Aim: This review explores the role of RCA in preventing medical errors, focusing on its application in healthcare settings, the systemic issues identified through RCA, and the effectiveness of interventions aimed at improving patient safety and care quality.

Methods: The study reviews existing literature on RCA in healthcare, analyzing case studies, guidelines by the Joint Commission, and other relevant reports. The research evaluates the use of RCA frameworks, particularly the 24-question guide and The Swiss Cheese Model, and how they aid in identifying system-level flaws.

Results: RCA investigations revealed that systemic errors, rather than individual mistakes, often contribute to sentinel events. Common contributing factors include ineffective communication, inadequate staffing, failure in procedural checks, and insufficient training. The implementation of corrective actions based on RCA findings has led to improvements in patient safety, reduced errors, and better resource allocation in healthcare institutions.

Conclusion: RCA is a critical tool in addressing medical errors and improving healthcare quality. By focusing on systemic factors, RCA offers a structured approach to identifying weaknesses in healthcare processes and formulating corrective actions. Its application has proven to enhance patient safety and reduce adverse events, leading to safer healthcare environments.