Root Cause Analysis of Diagnostic Error
Understanding the factors that contribute to diagnostic error is the key to improving diagnostic outcomes in the future. Each case of error provides lessons for how to prevent the next one.
The principles and practice of conducting RCA’s are well established, and authoritative advice is readily available from IHI, ASHRM, The Joint Commission, and the VA. None of these, however, was designed to consider the cognitive elements of patient care, and these cognitive aspects are typically the most relevant to understanding the origins of diagnostic error.
A comprehensive guide to conducting RCA’s of cases involving diagnosis is now available.
The guide complements the existing tools for conducting RCA's, and facilitates identification of both the system-related and the cognitive factors in each case. The approach is equally suitable for studying cases involving error (Safety 1), and cases where the diagnostic process went well (Safety 2).
Download the RCA Handbook