Quality Improvement, Root Cause Analysis, and Incident Reporting

A safety event creates two immediate responsibilities: protect the patient now and learn why the event was possible. Those responsibilities are related, but they are not the same task. Quality improvement asks, “How can this process produce safer, more reliable results?” Incident reporting alerts the organization that a deviation, harm, or near miss occurred. Root cause analysis examines how the event developed. The resulting corrective actions are then tested and monitored through quality-improvement methods. | Tool or process | Main question | Usual output | |---|---|---| | Incident report | What happened, and what immediate response was required? | A structured safety report | | Root cause analysis | Why did the event become possible, and which conditions contributed? | Contributing factors and system-level actions | | PDSA | Does a proposed change improve the process in actual practice? | Measured decision to adopt, adapt, or abandon the change | | Failure Mode and Effects Analysis | Where might a process fail before harm occurs? | Prospective risk controls | | Professional quality assurance | What does the individual clinician...