PATIENT SAFETY: IHI PS 201 ROOT
CAUSE ANALYSES AND ACTIONS WITH
COMPLETE SOLUTIONS
RCA2 can be useful in health care because:
(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
RCA2 makes health care safer by focusing on systems failures and improving
processes. It does not blame individuals for their actions and is not a method for
enforcing accountability. It is not a method for assessing the risk of introducing a new
idea or process.
Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. An RCA2
team is exploring what happened. They consider characteristics of the patient and staff
members. According to Charles Vincent, what other areas should they consider?
(A) Team factors
(B) Work environment
(C) Institutional context
(D) All of the above - ANSWER-D
What should leadership teams do to support the RCA2 process?
(A) Make sure there is at least one member of senior leadership on the team.
(B) Wait to conduct the RCA2 review for at least 30 days, to let the emotions
surrounding the incident subside.
(C) Make sure the RCA2 team has designated time to conduct a thorough review.
(D) All of the above - ANSWER-C
Conducting a high-quality RCA2 review takes time, and leadership needs to ensure
team members have time to devote to RCA2 tasks as part of their work. Senior
leadership does not need to be on the core investigative team; in fact, senior leaders
may be an impediment to drawing candid answers out of front-line staff. RCA2 activities
should be conducted quickly, before memories fade and attention is turned to newer
problems.
Which of the following is a method for identifying underlying causes of specific
problems?
, (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
The 'five whys' exercise is a useful tool to help teams get to the root causes of problems
by persistently asking "why?". Effective interview questions focus on identifying what
happened, not why. The Swiss cheese model is a conceptual framework that is helpful
to keep in mind as you explore cause and effect but is not itself an investigative method.
The best answer is all of the above. A wide range of factors influence medical
outcomes. Charles Vincent lists seven categories these factors, including: patient
characteristics, task factors, individual staff member characteristics, team factors, work
environment, organizational and management factors, and institutional context.
Which of the following scenarios would most likely call for RCA2?
(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
RCA2 is important to address adverse events as well as near misses, such as the near-
fall in answer choice C, that indicate a potential for harm to patients. Although the other
options may represent opportunities for improvement, they are not indicative of an
imminent threat to patient safety and would not trigger RCA2.
The goals of measuring effectiveness, an important step in the RCA2 process, include:
(A) Ensuring there's been compliance with the action items
(B) Evaluating the effectiveness of the action items
(C) Determining whether further corrective action is needed
(D) All of the above - ANSWER-D
The best answer is all of the above. Process measures confirm the action has been
implemented, while outcome measures tell you if the action was effective. Both are
necessary and will help inform improvers if their changes are sufficient or further action
is warranted.
Warning signs of an ineffective RCA2 include:
(A) Human error is identified as causing the event.
(B) Multiple corrective actions are identified.
CAUSE ANALYSES AND ACTIONS WITH
COMPLETE SOLUTIONS
RCA2 can be useful in health care because:
(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
RCA2 makes health care safer by focusing on systems failures and improving
processes. It does not blame individuals for their actions and is not a method for
enforcing accountability. It is not a method for assessing the risk of introducing a new
idea or process.
Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. An RCA2
team is exploring what happened. They consider characteristics of the patient and staff
members. According to Charles Vincent, what other areas should they consider?
(A) Team factors
(B) Work environment
(C) Institutional context
(D) All of the above - ANSWER-D
What should leadership teams do to support the RCA2 process?
(A) Make sure there is at least one member of senior leadership on the team.
(B) Wait to conduct the RCA2 review for at least 30 days, to let the emotions
surrounding the incident subside.
(C) Make sure the RCA2 team has designated time to conduct a thorough review.
(D) All of the above - ANSWER-C
Conducting a high-quality RCA2 review takes time, and leadership needs to ensure
team members have time to devote to RCA2 tasks as part of their work. Senior
leadership does not need to be on the core investigative team; in fact, senior leaders
may be an impediment to drawing candid answers out of front-line staff. RCA2 activities
should be conducted quickly, before memories fade and attention is turned to newer
problems.
Which of the following is a method for identifying underlying causes of specific
problems?
, (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
The 'five whys' exercise is a useful tool to help teams get to the root causes of problems
by persistently asking "why?". Effective interview questions focus on identifying what
happened, not why. The Swiss cheese model is a conceptual framework that is helpful
to keep in mind as you explore cause and effect but is not itself an investigative method.
The best answer is all of the above. A wide range of factors influence medical
outcomes. Charles Vincent lists seven categories these factors, including: patient
characteristics, task factors, individual staff member characteristics, team factors, work
environment, organizational and management factors, and institutional context.
Which of the following scenarios would most likely call for RCA2?
(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
RCA2 is important to address adverse events as well as near misses, such as the near-
fall in answer choice C, that indicate a potential for harm to patients. Although the other
options may represent opportunities for improvement, they are not indicative of an
imminent threat to patient safety and would not trigger RCA2.
The goals of measuring effectiveness, an important step in the RCA2 process, include:
(A) Ensuring there's been compliance with the action items
(B) Evaluating the effectiveness of the action items
(C) Determining whether further corrective action is needed
(D) All of the above - ANSWER-D
The best answer is all of the above. Process measures confirm the action has been
implemented, while outcome measures tell you if the action was effective. Both are
necessary and will help inform improvers if their changes are sufficient or further action
is warranted.
Warning signs of an ineffective RCA2 include:
(A) Human error is identified as causing the event.
(B) Multiple corrective actions are identified.
