Patient Safety: The PROACT Root Cause Analysis Approach

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ISBN 9781420087277
Cat# 87274



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Cat# E87274



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  • Teaches a proven approach that measures its effectiveness based on patient safety results rather than compliance
  • Demonstrates the Return-On-Investment for using RCA to reduce and/or eliminate undesirable outcomes
  • Helps readers understand the contribution of human error to physical consequences and explains how to identify conditions that are more prone to result in human error
  • Uses FMEA to proactively identify unacceptable risks and then uses RCA to prevent the risks from materializing
  • Uses Opportunity Analysis (OA) to identify the 20% of the events that have occurred in the past year that are causing 80% of hospital losses


Are you ready and willing to get to the root causes of problems? As Medicare, Medicaid, and major insurance companies increasingly deny payment for never events, it has become imperative that hospitals and doctors develop new ways to prevent these avoidable catastrophes from recurring. Proactive tools such as root cause analysis (RCA), basic failure mode and effects analysis (FMEA), and opportunity analysis (OA) are useful in preventing error, but in healthcare, such tools are often constrained by reticence to share information about mistakes and other problems inherent to the industry.

 ...well written and extremely applicable to health care. Every healthcare professional should have a copy.
   - Matthew C. Mireles, President / CEO, Community Medical Foundation for Patient Safety, Bellaire, Texas

Patient Safety: The PROACT® Root Cause Analysis Approach addresses the proactive methodologies and organizational paradigms that must change in order to support and sustain such activities in the interest of patient safety. Written by reliability expert Robert J. Latino, this book provides a perspective on patient care from outside the health industry and culture. It teaches a proven approach that measures its effectiveness based on patient safety results, rather than compliance, and demonstrates the Return-On-Investment for using RCA to reduce and/or eliminate undesirable outcomes.

Addressing the contribution of human error to physical consequences, Latino explores ways to identify conditions that are more prone to result in human error. It also uses FMEA to proactively identify unacceptable risks, and then uses the concepts of RCA to prevent risks from materializing.

Are you ready to be tenacious in your approach and completely honest in your assessment?
Root Cause Analysis requires courage and honesty.  When properly applied RCA will point out the problems and lead you to solutions.

Visit the author's website; find out if RCA is right for your organization 
Robert J. Latino has spent the past 10 years researching the differences in industrial culture versus the healthcare culture. In this book, he expertly makes the appropriate modifications to proven methodologies to successfully bridge the proactive technologies from industry to healthcare. Additional information, including an audio-visual presentation by the author, is available on the PROACT website at

Table of Contents

I. Recognizing and Supporting the Value of Proaction in Healthcare

The Need for Reliability Tools in Healthcare

Creating Management Support for a Proactive Environment to Succeed

II. Event Prioritization Techniques

Failure Classification

Basic Failure Mode and Effects Analysis: The Traditional Approach

Opportunity Analysis (OA): The Modified Approach

III. Understanding Root Cause Analysis

Understanding Why Things Go Wrong

The PROACT® Root Cause Analysis (RCA) Methodology

IV. The PROACT ® Root Cause Analysis (RCA) Methodology

Preserving Event Data

Ordering the Analysis Team

Analyzing the Data: Introducing the Logic Tree

Communicate Findings and Recommendations

Tracking for Results

V. A Software Technology to Support Proaction

Automating Proactive Analyses: The Utilization of the PROACT® Suite Software Solution (Version 3.6+)

VI. From Theory to Practical Application

Case Studies

Appendix: Paradigm Shift Summary


Author Bio(s)

Editorial Reviews

"Mr. Latino’s book reflects how RCA can be used to address serious patient safety risk opportunities… . I believe this book would be welcomed in the healthcare field."

—Fay A. Rozovsky, JD, MPH, The Rozovsky Group, Inc./RMS

"… this book is helpful for the healthcare industry to utilize for improving patient quality and safety. The methodology provides a systematic approach to finding causes to chronic failures as well as root causes to undesirable outcomes."

—Shelby Forgacs, RN, Quality and Risk Evaluator

"I believe this book will be an eye opener for healthcare leadership and a great tool for healthcare professionals in risk, quality, and safety management."

—Anne Flood, RN, MA, Union Memorial Hospital/MedStar Health