Abstract
Root Cause Analysis and Action (RCA2) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and the development of systems-level interventions. We previously described how human factors tools can be integrated into RCA2 to create a robust process called HFACS-RCA2. Prior analyses of qualitative data associated with an 18-month implementation project at a large academic health center indicated that HFACS-RCA2 fosters a more comprehensive human factors analysis of serious patient harm events and the identification of broader system interventions. The present study builds on this prior research by presenting the analysis of actual recommendations extracted from RCA reports. Results corroborate qualitative stakeholder findings that HFACS-RCA2 produced recommendations that were stronger and included more substantive changes compared to former RCA methods.
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