Department of Veterans Affairs National Center for Patient Safety –Root Cause Analysis

The National Center for Patient Safety uses a multi-disciplinary team approach, known as Root
Cause Analysis – RCA – to study health care-related adverse events and close calls. The goal of
the RCA process is to find out what happened, why it happened, and how to prevent it from
happening again. Because the Center’s Culture of Safety is based on prevention, not punishment,
RCA teams investigate how well patient care systems function. The focus is on the “how” and
the “why,” not on the “who.” Through the application of Human Factors Engineering (HFE)
approaches, the National Center for Patient Safety aims to support human performance.

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