IHI PS 201: ROOT CAUSE ANALYSIS &
ACTIONS WITH COMPLETE SOLUTIONS
a. An occupational therapist quits after only three days on the job.
b. A physician is convinced that there is a better way to deliver pain medications on her
unit.
c. A social worker catches a patient who is falling out of bed.
d. An administrator needs to develop a balanced budget.
Answer: C - ANSWER-Which of the following is one of the Five Rules of Causation?
a. The surgeon didn't listen to the nurse.
b. The patient was male.
c. The hierarchy in the operating room had a negative effect upon communication.
d. All of the above.
Answer: C - 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?
a. 'Five Whys' exercise
b. Swiss cheese model of accident causation
c. Asking people in the system via 1:1 interviews why they believe an event occurred.
d. All of the above
Answer: A - ANSWER-Which of the following is a method for identifying underlying
causes of specific problems?
a. Posting warning signs
b. Increasing staffing
c. Conducting additional training
, d. Standardizing processes.
Answer: D - ANSWER-Which of the following types of interventions is likely to be most
effective for improving safety?
a. With a goal of 99% of patients receiving calls within 2 days of their results: Have the
phlebotomy lab automatically generate a list of all patients who had INRs drawn that
day and email them to the nurse, with space to note if the nurse has reached the patient
with the results.
b. Patients awaiting lab results should be given access to MyChart, a part of the
electronic health record that allows them to access their lab results themselves.
c. The nurse in charge of calling patients with their results should be replaced.
d. Patients need to have their INRs checked more frequently.
Answer: C - ANSWER-Which of the following scenarios would most likely call for
RCA2?
a. It holds people accountable for their actions.
b. It helps to identify system failures that can be corrected.
c. It helps to assess the potential risk of introducing a new idea or process.
d. All of the above.
Answer: B - ANSWER-RCA2 can be useful in health care because:
a. 'Five whys' exercise
b. Cause and effect diagram
c. Harm-based prioritization matrix
d. 'Five whys' exercise AND Cause and effect diagram
Answer: D - ANSWER-Which of the following is a helpful tool/method for identifying
underlying causes of problems?
a. Doing a complete and thorough reconstruction of what happened before the event
b. Defining what should have happened for the patient
ACTIONS WITH COMPLETE SOLUTIONS
a. An occupational therapist quits after only three days on the job.
b. A physician is convinced that there is a better way to deliver pain medications on her
unit.
c. A social worker catches a patient who is falling out of bed.
d. An administrator needs to develop a balanced budget.
Answer: C - ANSWER-Which of the following is one of the Five Rules of Causation?
a. The surgeon didn't listen to the nurse.
b. The patient was male.
c. The hierarchy in the operating room had a negative effect upon communication.
d. All of the above.
Answer: C - 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?
a. 'Five Whys' exercise
b. Swiss cheese model of accident causation
c. Asking people in the system via 1:1 interviews why they believe an event occurred.
d. All of the above
Answer: A - ANSWER-Which of the following is a method for identifying underlying
causes of specific problems?
a. Posting warning signs
b. Increasing staffing
c. Conducting additional training
, d. Standardizing processes.
Answer: D - ANSWER-Which of the following types of interventions is likely to be most
effective for improving safety?
a. With a goal of 99% of patients receiving calls within 2 days of their results: Have the
phlebotomy lab automatically generate a list of all patients who had INRs drawn that
day and email them to the nurse, with space to note if the nurse has reached the patient
with the results.
b. Patients awaiting lab results should be given access to MyChart, a part of the
electronic health record that allows them to access their lab results themselves.
c. The nurse in charge of calling patients with their results should be replaced.
d. Patients need to have their INRs checked more frequently.
Answer: C - ANSWER-Which of the following scenarios would most likely call for
RCA2?
a. It holds people accountable for their actions.
b. It helps to identify system failures that can be corrected.
c. It helps to assess the potential risk of introducing a new idea or process.
d. All of the above.
Answer: B - ANSWER-RCA2 can be useful in health care because:
a. 'Five whys' exercise
b. Cause and effect diagram
c. Harm-based prioritization matrix
d. 'Five whys' exercise AND Cause and effect diagram
Answer: D - ANSWER-Which of the following is a helpful tool/method for identifying
underlying causes of problems?
a. Doing a complete and thorough reconstruction of what happened before the event
b. Defining what should have happened for the patient
