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Root-Cause Analysis for Enhancing Public Health Emergency Preparedness

A Brief Report of a Salmonella Outbreak in the Alamosa, Colorado, Water Supply

Piltch-Loeb, Rachael MSPH; Kraemer, John JD, MPH; Nelson, Christopher PhD; Savoia, Elena MD, MPH; Osborn, David R. BS; Stoto, Michael A. PhD

Journal of Public Health Management and Practice: November/December 2018 - Volume 24 - Issue 6 - p 542–545
doi: 10.1097/PHH.0000000000000763
Research Reports: Practice Brief Report

To demonstrate how public health systems can use root-cause analysis (RCA) to improve learning from critical incidents, the research team utilized a facilitated look-back meeting to examine the public health systems' response to a Salmonella outbreak in the water supply in Alamosa, Colorado. We worked with public health, emergency management agencies, and other stakeholders to identify response challenges related to public health emergency preparedness capabilities, root causes, and lessons learned. The results demonstrate that RCA can help identify systems issues that, if addressed, can improve future responses. Furthermore, RCA can identify more basic issues that go beyond a specific incident or setting, such as the need for effective communication and coordination throughout the public health system, and the social capital needed to support it.

College of Global Public Health, New York University, New York City, New York (Ms Piltch-Loeb); Department of Health Systems Administration (Drs Kraemer and Stoto) and O'Neill Institute for National and Global Health Law (Dr Kraemer), Georgetown University, Washington, District of Columbia; RAND Corporation, Santa Monica, California (Dr Nelson); Pardee RAND Graduate School, Santa Monica, California (Dr Nelson); Division of Policy Translation and Leadership Development (Dr Savoia), Harvard T. H. Chan School of Public Health (Dr Stoto), Boston, Massachusetts; and San Luis Valley Region, Colorado Division of Homeland Security and Emergency Management, Centennial, Colorado (Mr Osborn).

Correspondence: Rachael Piltch-Loeb, MSPH, College of Global Public Health, New York University, 715 Broadway, New York, NY 10003 (

The authors are grateful to the many individuals who gave their time to participate in the root-cause analysis process on which this project depended so heavily. The authors acknowledge funding support from the US Centers for Disease Control and Prevention supplement to grant no. 5PO1TP000307-05 Preparedness and Emergency Response Research Center—Linking Assessment to Measurement and Performance in Public Health Emergency Preparedness Exercises into Practice.

The authors declare no conflicts of interest.

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