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A multidisciplinary team was created to investigate safety events. The team developed standard work including key stakeholder notification of the event, a huddle to facilitate immediate mitigation of risk, staff resiliency support, a consistent interview approach, analysis of investigation data, and an accountability meeting to ensure consensus on steps required to prevent future harm. Sustainability is hardwired through ongoing monitoring of metrics. The baseline data collection period was January 2020 through December 2022 (<jats:italic>n<\/jats:italic>\u00a0=\u00a041) and the intervention period was January 2023 through December 2023 (<jats:italic>n<\/jats:italic>\u00a0=\u00a025). First interview time was reduced from 2 days (SD\u00a0=\u00a02.38) to 1 day (SD\u00a0=\u00a01.20, <jats:italic>p<\/jats:italic>\u00a0&lt;\u00a00.0001). Mean event finalization decreased from 31 (SD\u00a0=\u00a013.75) to 13 days (SD\u00a0=\u00a06.75, <jats:italic>p<\/jats:italic>\u00a0&lt;\u00a00.001). Staff nervousness score decreased from 32.40 pre\u2010interview to 13.96 post\u2010interview (<jats:italic>p<\/jats:italic>\u00a0&lt;\u00a00.001) on a 100\u2010point analog scale. Non\u2010fall related safety events decreased from an average of 10.5 per year between July 1, 2021\u2013June 30, 2023 to a total of 6 between July 1, 2023\u2013June 30, 2024 (<jats:italic>p<\/jats:italic>\u00a0=\u00a00.05).<\/jats:p>","DOI":"10.1002\/jhrm.21587","type":"journal-article","created":{"date-parts":[[2024,12,20]],"date-time":"2024-12-20T16:29:24Z","timestamp":1734712164000},"page":"15-25","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Creation of root cause analysis and action (RCA<sup>2<\/sup>) standard work by a multidisciplinary team to prevent harm, reduce bias, and improve safety culture"],"prefix":"10.1002","volume":"44","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-1945-0822","authenticated-orcid":false,"given":"Donise","family":"Musheno","sequence":"first","affiliation":[{"name":"Division of Quality, Safety and Regulatory Affairs Penn Medicine Lancaster General Health  Lancaster Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary","family":"Harnish","sequence":"additional","affiliation":[{"name":"Division of Quality, Safety and Regulatory Affairs Penn Medicine Lancaster General Health  Lancaster Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin","family":"Roberts","sequence":"additional","affiliation":[{"name":"Division of Quality, Safety and Regulatory Affairs Penn Medicine Lancaster General Health  Lancaster Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Smokowicz","sequence":"additional","affiliation":[{"name":"Division of Quality, Safety and Regulatory Affairs Penn Medicine Lancaster General Health  Lancaster Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2024,12,20]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2018.0738"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.33940\/001c.74752"},{"key":"e_1_2_7_4_1","volume-title":"RCA2: Improving Root Cause Analyses and Actions to Prevent Harm","author":"National Patient Safety Foundation","year":"2015"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.4997\/jrcpe.2018.306"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1002\/jhrm.21456"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2016-005511"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913\u2010023\u201010164\u20109"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1002\/jhrm.21454"},{"key":"e_1_2_7_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsr.2023.07.012"}],"container-title":["Journal of Healthcare Risk Management"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jhrm.21587","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,31]],"date-time":"2025-01-31T14:44:10Z","timestamp":1738334650000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/jhrm.21587"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,20]]},"references-count":9,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2025,1]]}},"alternative-id":["10.1002\/jhrm.21587"],"URL":"https:\/\/doi.org\/10.1002\/jhrm.21587","archive":["Portico"],"relation":{},"ISSN":["1074-4797","2040-0861"],"issn-type":[{"value":"1074-4797","type":"print"},{"value":"2040-0861","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,20]]},"assertion":[{"value":"2024-08-21","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-12-02","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-12-20","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}