Root Cause Analysis, Action, and Audit (RCA3): A Novel Approach to Sustainably Reduce Medication Errors

Medical errors threaten patient safety. Although root cause analysis (RCA) is commonly used to investigate medication errors, such errors often recur, posing ongoing risks to patient safety. The RCA2 framework, introduced by the National Patient Safety Foundation, aimed to strengthen traditional RCA by emphasizing action-oriented outcomes. To further enhance sustainability, we implemented RCA3-an iterative process adding follow-up audits to evaluate long-term effectiveness of corrective actions. We aim to highlight RCA3's ability to maintain the effectiveness of interventions in preventing medication errors.

After a hydralazine overdose in a pregnant patient with pre-eclampsia, we conducted RCA2 and audited recommendations 3 weeks post-implementation and re-evaluated after 1 year to identify any lapses due to impracticality or lack of sustainability. This enhanced approach, called RCA3, builds on RCA2 by adding routine audits assessing implementation, long-term effectiveness, and medication error recurrence within 12 months.

Compared with lapses identified during the RCA2 re-audit, no medication errors reoccurred for over a year after implementing RCA3 recommendations. Successful interventions focused on modifying computerized physician order entry systems (CPOE) and added specific medication preparation/disposal instructions to departmental guidelines and CPOE order sets.

RCA3, a novel approach incorporating sustainability audits, may be more effective than the standard RCA2 process in preventing medication error recurrence. RCA3 prioritizes effective, practical, and sustainable actions while distinguishing passive abandonment from active roll back. Thus, RCA3 offers health care systems a valuable tool to enhance patient safety and prevent errors.