Creation of root cause analysis and action (RCA) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture.

This project aimed to (1) develop a multidisciplinary team to rapidly conduct event analysis, (2) create tools to standardize event communication, (3) expand resiliency support provided to staff, and (4) decrease cycle time between event occurrence and action implementation. A multidisciplinary team was created to investigate safety events. The team developed standard work including key stakeholder notification of the event, a huddle to facilitate immediate mitigation of risk, staff resiliency support, a consistent interview approach, analysis of investigation data, and an accountability meeting to ensure consensus on steps required to prevent future harm.