IHI PS 201: ROOT CAUSE ANALYSES
AND ACTIONS
Quinn is a three-year-old boy with a congenital heart malformation. While recovering in
the pediatric intensive care unit after surgical correction, he is accidentally given ten
times the appropriate dose of heparin. Although he suffers no permanent injuries, the
leaders of the hospital decide to conduct a RCA2. As they assemble the team, which of
the following would you recommend? - ANSWER-Create a team of members who fulfill
several roles.
What should leadership teams do to support the RCA2 process? - ANSWER-Make sure
the RCA2 team has designated time to conduct a thorough review.
Which of the following is a method for identifying underlying causes of specific
problems? - ANSWER-'Five whys' exercise
Which of the following is one of the Five Rules of Causation? - ANSWER-Human error
must have a preceding cause.
A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner,
by his cardiologist. He goes to clinic weekly to have his INR, a measure of how thin his
blood is, checked. One week he does not get a call after his bloodwork, and the week
after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6,
indicating his blood is dangerously thin.
A team conducts an RCA2. One root cause the team identifies is that the cardiology
clinic does not have a specific method to make sure they reach all patients with INRs
and communicate abnormal results and associated updates to their plan of care.
Which of the following is the best recommended action statement? - ANSWER-
An RCA2 team is launching an investigation of a surgical error. If they complete an
effective review, which of the following is an example of a root cause they might
identify? - ANSWER-The hierarchy in the operating room had a negative effect upon
communication.
Which of the following is a recommendation for effective interviewing during RCA2? -
ANSWER-Set the right tone by expressing your own regret about what happened.
Which is the following is an example of an engineering control (forcing function)? -
ANSWER-
Which of the following types of interventions is likely to be most effective for improving
safety? - ANSWER-
AND ACTIONS
Quinn is a three-year-old boy with a congenital heart malformation. While recovering in
the pediatric intensive care unit after surgical correction, he is accidentally given ten
times the appropriate dose of heparin. Although he suffers no permanent injuries, the
leaders of the hospital decide to conduct a RCA2. As they assemble the team, which of
the following would you recommend? - ANSWER-Create a team of members who fulfill
several roles.
What should leadership teams do to support the RCA2 process? - ANSWER-Make sure
the RCA2 team has designated time to conduct a thorough review.
Which of the following is a method for identifying underlying causes of specific
problems? - ANSWER-'Five whys' exercise
Which of the following is one of the Five Rules of Causation? - ANSWER-Human error
must have a preceding cause.
A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner,
by his cardiologist. He goes to clinic weekly to have his INR, a measure of how thin his
blood is, checked. One week he does not get a call after his bloodwork, and the week
after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6,
indicating his blood is dangerously thin.
A team conducts an RCA2. One root cause the team identifies is that the cardiology
clinic does not have a specific method to make sure they reach all patients with INRs
and communicate abnormal results and associated updates to their plan of care.
Which of the following is the best recommended action statement? - ANSWER-
An RCA2 team is launching an investigation of a surgical error. If they complete an
effective review, which of the following is an example of a root cause they might
identify? - ANSWER-The hierarchy in the operating room had a negative effect upon
communication.
Which of the following is a recommendation for effective interviewing during RCA2? -
ANSWER-Set the right tone by expressing your own regret about what happened.
Which is the following is an example of an engineering control (forcing function)? -
ANSWER-
Which of the following types of interventions is likely to be most effective for improving
safety? - ANSWER-
