Creation of root cause analysis and action (RCA2) 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. Sustainability is hardwired through ongoing monitoring of metrics. The baseline data collection period was January 2020 through December 2022 (n = 41) and the intervention period was January 2023 through December 2023 (n = 25). First interview time was reduced from 2 days (SD = 2.38) to 1 day (SD = 1.20, p < 0.0001). Mean event finalization decreased from 31 (SD = 13.75) to 13 days (SD = 6.75, p < 0.001). Staff nervousness score decreased from 32.40 pre-interview to 13.96 post-interview (p < 0.001) on a 100-point analog scale. Non-fall related safety events decreased from an average of 10.5 per year between July 1, 2021-June 30, 2023 to a total of 6 between July 1, 2023-June 30, 2024 (p = 0.05).