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About this IHI Virtual Expedition

​Root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occur. While RCA has been part of health care and patient safety for more than 15 years, success has been variable both within and across institutions.

This Institute for Healthcare Improvement (IHI) Virtual Expedition will explore the process of Root Cause Analyses and Actions (RCA2). Expanding on RCA, RCA2 is  used to drive improvement when it comes to reviewing events that cause or may cause serious harm, and in developing and implementing sustainable and measurable actions that prevent future harm to both patients and staff.

What You'll Learn

At the end of this Virtual Expedition, participants will be able to:

  • Identify the current state of root cause analysis (RCA), and why improvements are essential
  • Describe the methodology and processes associated with RCA2
  • Utilize tools that are used in the RCA2 process
  • List approaches for evaluating the success of RCA2

This IHI Virtual Expedition is approved for a total of 6 continuing education credits for physicians, nurses and pharmacists.


Session 1: Understanding RCA2: The Process of Event Review
Date: Wednesday, January 24, 2018, 12:00 PM–1:00 PM ET

Session 2: Identifying and Classifying Events for Review
Date: Wednesday, February 7, 2018, 12:00 PM–1:00 PM ET

Session 3: Event Review: Determining the Team and Engaging the Patient
Date: Wednesday, February 21, 2018, 12:00 PM–1:00 PM ET

Session 4: Event Review: Finding and Mapping the Facts
Date: Wednesday, March 7, 2018, 12:00 PM–1:00 PM ET

Session 5: Event Review: Determining the Cause and Effective Actions
Date: Wednesday, March 21, 2018, 12:00 PM–1:00 PM ET

Session 6: Implementation, Measurement, and Feedback
Date: Wednesday, April 4, 2018, 12:00 PM–1:00 PM ET


Rollin J (Terry) FairbanksRollin J “Terry” Fairbanks, MD, MS, FACEP, CPPS is the Founding Director of the National Center for Human Factors in Healthcare, and Assistant Vice President, Ambulatory Quality & Safety at MedStar Health, a not-for-profit healthcare system in the Baltimore, Maryland, and Washington DC, USA region, with 10 hospitals, 280 outpatient sites, and 31,000 associates. Dr. Fairbanks is Professor of Emergency Medicine at Georgetown University and practices at the MedStar Washington Hospital Center. Dr. Fairbanks holds a master’s degree in human factors engineering/industrial systems engineering, and is adjunct associate professor of Industrial Systems Engineering at the University at Buffalo. His safety work has been funded by the NIH, AHRQ, ONC, Pew Foundation, American Medical Association, and several foundations. He has served in many national and international advisory roles in healthcare safety, including as a member of the NPSF Board of Advisors, the AAMI Board of Directors, and a member of the United Kingdom Health IT Advisory Committee. He has served as an advisor to the US, Spanish, Australian, and British governments.  Dr. Fairbanks has authored more than 120 publications and a book on healthcare safety and human factors engineering, and he has been a driving force in the transformation of MedStar Health’s approach to Quality & Safety, and systems-based event reviews. Dr. Fairbanks is a is a national and international keynote speaker and is listed in this year’s Becker’s Hospital Review “Top 50 Experts Leading the Field of Patient Safety.” Dr. Fairbanks was a member of the core working group that developed RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

James Bagian James P. Bagian, MD, PE, Director for Healthcare Engineering and Patient Safety, University of Michigan is focused on creating solutions that will make healthcare safer, more effective, and efficient for patients. Dr. Bagian’s primary interest and expertise are in the development and implementation of multidisciplinary programs and projects that involve the integration of engineering, medical/life sciences, and human factor disciplines. He is applying the majority of his attention to the application of systems engineering approaches to the analysis of medical adverse events, and the development and implementation of suitable corrective actions that will enhance patient safety primarily through preventive means. Dr. Bagian directs the Center for Healthcare Engineering and Patient Safety (CHEPS), and he is an elected member of the National Academy of Medicine and the National Academy of Engineering. Previously, he served as the first chief patient safety officer and founding director of the National Center for Patient Safety (NCPS) at the U.S. Department of Veterans Affairs (VA). Dr. Bagian was a member of the core working group that developed RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

Katherine Kellogg Kathryn M. Kellogg, MD, MPH, is a researcher and patient safety professional with significant experience applying human factors principals to patient safety issues. As the Associate Medical Director, she provides clinical expertise for grants and contracts at the National Center for Human Factors in Healthcare. She also directs the human factors event reviews and hazard analyses, and serves as a liaison between the Human Factors Center and the MedStar Safety team, integrating safety science into innovative safety interventions implemented across the system. Dr. Kellogg also conducts research on patient safety issues, and is currently the principal investigator for the Center’s pilot test of the Agency for Healthcare Research and Quality’s Quality and Safety Review System. Dr. Kellogg’s research interests include adverse event review, a topic on which she has published original research, and physician stress and burnout. She studied medicine at the University of Rochester School of Medicine and Dentistry, and earned her Master in Public Health from The Dartmouth Institute, with a focus in systems approach to healthcare improvement. She completed her residency in Emergency Medicine at Vanderbilt University. Dr. Kellogg’s work has been supported by the Agency for Healthcare Research and Quality (AHRQ) and the MedStar Health Research Institute. Dr. Kellogg is also a board-certified Emergency Medicine Physician who practices and teaches at MedStar Washington Hospital Center, and is an Assistant Professor of Emergency Medicine at Georgetown University.

Setj Krevat Seth A. Krevat, MD, FACP, is the Assistant Vice President of Safety at MedStar Health, an Assistant Professor of Clinical Medicine at Georgetown University School of Medicine, and an Attending Physician of Palliative Medicine at MedStar Georgetown University Hospital. Dr. Krevat was recruited to MedStar Health to lead the development of their comprehensive safety program. He is responsible and accountable for all patient safety and risk reduction programs across MedStar Health. Under his guidance, MedStar has experienced massive culture change: implemented the tools and behaviors of a High Reliability Organization, implemented a new event review process to evaluate serious safety events through the lens of safety science, and leveraged the value of increasing numbers of incident reports submitted by MedStar’s workforce. Dr. Krevat received a Bachelor’s Degree in economics and English from Tufts University and a Medical Doctorate from Georgetown University School of Medicine.