Patient safety and medicines3 hours
Incident Reporting and Patient Safety Events
Reporting incidents, near misses and unsafe conditions: writing a useful report, PSO protection, state and CMS duties, FDA and ISMP routes.
US$89DetailsAdd to cart
Patient safety and medicines
Root Cause Analysis (RCA²) for Health Professionals
How to analyze serious events, write causal statements and choose actions that actually prevent recurrence
- 3hours
- 10sections
- 20final questions
- 80%pass mark
- PDFcertificate
- Online and self-paced, on any device
- Reflective account template
- Knowledge checks in every section
- Instant certificate of completion
What you will learn
- Explain the origins and purpose of RCA² and how it differs from traditional root cause analysis.
- Describe the US requirements that drive event analysis, including The Joint Commission's comprehensive systematic analysis, CMS QAPI rules, VA policy and Patient Safety Act protections.
- Prioritize events and close calls using the Safety Assessment Code matrix.
- Distinguish blameworthy events from events suitable for RCA² and explain how each is handled.
- Charter an RCA² with an appropriate scope, timeline and team composition.
- Preserve evidence, conduct open, non-judgmental interviews and build initial and final flow diagrams.
- Use triage questions and cause-and-effect diagrams, and write causal statements that meet the Five Rules of Causation.
- Classify actions using the action hierarchy and write specific, owned, time-bound actions with process and outcome measures.
- Describe the roles of leaders, boards, patients and families, and recognize the warning signs of an ineffective review.
- Apply RCA² principles in small practices and describe an event to a state board in a way that combines system context with personal accountability.
Who this course is for
U.S. licensed health professionals: physicians, PAs, nurses and APRNs, pharmacists, dentists and dental hygienists and other licensees, including those who lead, join or take part in event reviews.
Physicians (MD/DO) Nurses (RN, LPN, APRN) Pharmacists Dentists and hygienists Physician assistants Therapists, counselors and other licensees
After a concern
Structured learning and a written reflection to show insight after a complaint, an investigation or a board inquiry.
Routine learning
Focused learning on a core standard of practice, with a certificate and reflection for your portfolio.
About this course
This course teaches the root cause analysis and action method (RCA²) used in US health care, step by step. It covers the origins of the method at the VA National Center for Patient Safety and its redesign by the National Patient Safety Foundation, The Joint Commission's comprehensive systematic analysis, CMS quality requirements and Patient Safety Act protections; risk-based prioritization with the Safety Assessment Code; blameworthy events; chartering and team design; evidence preservation, interviewing and flow diagrams; triage questions, cause-and-effect diagrams and the Five Rules of Causation; analyst bias; the action hierarchy; action statements and measures; leadership, feedback and aggregated reviews.
It is written for physicians, PAs, nurses and APRNs, pharmacists, dentists and dental hygienists, and allied licensees in any US state and any setting: hospitals, ambulatory surgery centers, long-term care, home health, community pharmacies, dental offices and physician practices. Cases are set across states including Oregon, Ohio, Michigan, Pennsylvania, Texas, South Carolina and California, and a complete worked RCA² follows one event from first report to six-month follow-up.
Most licensees will take part in an event review as a reporter, an interviewee, a team member or a process owner, and many reviews still end with retraining and a memo. Knowing how a good RCA² works lets you contribute well, challenge blame and weak actions, protect yourself appropriately and, if a board ever asks about an event, describe both the system context and your own learning credibly. The course goes deeper into analysis methods than this site's courses on incident reporting, human factors and disclosure.
Course details
- Learning time
- Approximately 3 hours (estimated learning time including knowledge checks, reflection and assessment)
- Standards covered
- NPSF RCA²: Improving Root Cause Analyses and Actions to Prevent Harm (2015; version 2, 2016); VHA National Center for Patient Safety Guide to Performing a Root Cause Analysis (2021) and Triage Questions; The Joint Commission Sentinel Event Policy (comprehensive systematic analysis); CMS QAPI, 42 CFR 482.21; Patient Safety and Quality Improvement Act of 2005 and 42 CFR Part 3; 38 U.S.C. 5705; AMA Code of Medical Ethics Opinion 8.6
- Format
- Self-paced, gated lessons with knowledge checks, case studies and reflection
- Assessment
- 20 scenario-based questions, 80% to pass (16 of 20)
- Outcome
- Certificate of completion and a written reflection for your learning record
Course curriculum
10 sections · 25 lessons · 3 hours · 20-question final assessment
-
1RCA² in US health care: purpose and framework3 lessons
- From "root cause" to RCA²: why the method changed
- The US framework that drives event analysis
- Your role as a licensee in an RCA²
-
2Deciding what to analyze and setting up the review3 lessons
- Risk-based prioritization and the Safety Assessment Code
- Blameworthy events and the boundary with accountability
- Chartering the review and building the team
-
3Gathering the facts3 lessons
- Immediate actions and securing the evidence
- Interviewing: getting the real story
- Mapping what happened: flow diagrams
-
4Finding why: analysis tools4 lessons
- Triage and triggering questions
- Cause-and-effect diagrams and the limits of "five whys"
- Writing causal statements: the Five Rules of Causation
- Bias and other traps in the analysis
-
5Actions that prevent recurrence3 lessons
- The action hierarchy in detail
- Writing action statements that will be carried out
- Measuring whether actions worked
-
6Leadership, feedback and program quality3 lessons
- Leadership, the board and the RCA² program
- Feedback, patients and families
- Program quality: warning signs, aggregated reviews and critiques
-
7RCA² across settings and in your professional life3 lessons
- RCA² in small practices and community settings
- A complete RCA² from start to finish
- RCA², your license and your state board
-
8Conclusion and key points1 lesson
- Conclusion and key points
-
9References and further reading1 lesson
- References and further reading
-
10Your reflective account1 lesson
- Your reflective account
Assessment and certificate
Final assessment
20scenario-based questions
- Pass mark 80%: 16 correct out of 20
- Knowledge checks in each section as you go
- Tests whether you can apply the standards, not recall a page
- Not passed yet? Review the sections and retake it
Certificate of completion
Certificate of completion. Not CE or CME credit unless accepted by your board.
- Your name, the course title and the hours
- Completion date and a unique certificate ID that can be verified
- Ready to download as a PDF as soon as you complete the course
Your reflective account
The course includes a structured reflective account template: guided prompts to record what you learned, how you will apply it and how the change will show in your practice. It gives you written evidence of insight after a concern, and a ready record for your learning portfolio.
Write it in your own words and leave out anything that could identify a patient, a colleague or a case. If you have an open complaint or case, talk to your adviser before reflecting on it in writing.
Questions about this course
How does RCA² differ from a traditional root cause analysis?
RCA², redesigned by the National Patient Safety Foundation from the VA method, puts the emphasis on action: risk-based prioritization, stronger system-level actions, measures and leadership follow-up. Traditional reviews often ended with retraining and a memo. The course shows each step and why it matters.
What are the Five Rules of Causation?
They require causal statements to show cause and effect clearly, avoid negative descriptors such as 'poorly', identify the cause behind each human error, identify the cause behind each procedural deviation, and recognize that failure to act is only causal when there was a pre-existing duty. The course gives examples of each.
Are blameworthy events handled through RCA²?
No. Events involving criminal acts, suspected impairment, patient abuse or intentional unsafe acts are referred to other processes. The course explains how to distinguish blameworthy events from those suited to RCA², and how this protects the integrity of a non-punitive review.
I'm a solo practitioner. Is RCA² relevant to me?
Yes. The course adapts RCA² principles for small practices, dental offices and community pharmacies, and shows how to describe an event to a state board by combining system context with personal accountability. One worked RCA² traces a single event from the first report through to the six-month follow-up.
How long is the RCA² training and what does it cost?
Roughly three hours online, $89, starting when you enroll. Checks per section, a 20-question final with an 80% pass mark, then a certificate and a reflection on an event you analyze yourself. Study at whatever pace suits you. Small practices get adapted templates.
How this course was built
Official sources only
Every legal and regulatory point comes from primary sources: state practice acts and board rules, federal law and national professional codes of ethics. Anything we cannot confirm is left out.
Original, edition by edition
Lessons, scenarios and assessment questions are written by us for each edition separately, then checked for accuracy, teaching quality and fair assessment before publication.
Reviewed when rules change
When a code, standard or law changes, the affected courses are reviewed and updated. Reported errors in legal or regulatory facts are corrected first.
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