Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA(2)) has become an area of interest. If performed thoroughly, RCA(2) has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes. Resident engagement in the RCA(2) process has the dual benefit of educating trainees in patient safety and producing meaningful changes to patient care that may not occur with traditional quality improvement initiatives. The RCA(2) process described in this article can provide a model for the development of quality improvement programs. In this article, the authors discuss the history and methods of the RCA(2) process, provide a stepwise approach, and give a case example.