Root Cause Analysis and Medical Error Prevention: An Integrated Approach Involving Physical Therapy, Medical Informatics, and Healthcare Administration

Abstract

Background: Medical error is a leading cause of mortality and morbidity globally, representing a critical systemic challenge rather than merely individual failure. The profound human and economic costs demand a shift from a culture of blame to one of proactive safety and continuous improvement.

Aim: This article advocates for an integrated, interdisciplinary approach to medical error prevention, with Root Cause Analysis (RCA) as a cornerstone methodology. It aims to demonstrate how combining the expertise of clinical staff, physical therapists, health informatics professionals, and administrators can effectively identify and mitigate the latent system vulnerabilities that lead to patient harm.

Methods: The article details the structured RCA process as mandated by accrediting bodies like The Joint Commission. This involves forming a multidisciplinary team, meticulous data collection (interviews, records review), and the use of analytical tools like cause-and-effect diagrams to trace adverse events back to their contributory factors across people, processes, and technology.

Results: Effective RCA moves beyond weak recommendations (e.g., re-education) to implement strong, sustainable interventions. These include forcing functions in electronic health records, standardized checklists, barcode medication administration, and workflow redesign. Case illustrations demonstrate how such systemic changes can prevent errors in medication administration, surgery, and diagnostics.

Conclusion: A sustainable safety culture requires a coordinated, interprofessional effort. By leveraging RCA to drive systemic change and empowering all team members—from clinicians to administrators—healthcare organizations can transform incidents of harm into powerful opportunities for learning and prevention.