PS 201- ROOT CAUSES ANALYSES
EXAM QUESTIONS AND ANSWERS
(GRADED A+)
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder. The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
You are evaluating whether an RCA2 should be performed on this event. What would
you say is the ACTUAL severity of this event? (Hint: Refer to the four severity
categories from the SAC Matrix.) - ANSWER-Minor
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder. The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
What do you think is the POTENTIAL severity of this event? (Hint: Refer to the four
severity categories from the SAC Matrix.) - ANSWER-catastrophic
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder.The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
Assuming you judge the probability of a patient experiencing the most severe outcome
as "occasional," should the organization proceed with RCA2? (Hint: Refer to the Safety
Assessment Code Matrix.) - ANSWER-yes
RCA2 can be useful in health care because: - ANSWER-It helps to identify system
failures that can be corrected.
What is the ultimate purpose of conducting RCA2 after an adverse event? - ANSWER-
Taking action to reduce the risk of future harm
Which of the following scenarios would most likely call for RCA2? - ANSWER-A social
worker catches a patient who is falling out of bed
EXAM QUESTIONS AND ANSWERS
(GRADED A+)
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder. The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
You are evaluating whether an RCA2 should be performed on this event. What would
you say is the ACTUAL severity of this event? (Hint: Refer to the four severity
categories from the SAC Matrix.) - ANSWER-Minor
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder. The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
What do you think is the POTENTIAL severity of this event? (Hint: Refer to the four
severity categories from the SAC Matrix.) - ANSWER-catastrophic
At your hospital, where you're a patient safety officer, nursing staff members were
providing routine morning care to a patient. They were washing a patient who was
seated in a chair. As this was taking place, he slid off the chair, hitting his face, hip, and
shoulder.The patient was examined by a doctor at 7:55 AM and transferred to radiology
for further evaluation. The physician ordered x-rays and saw no fractures. Additional
neurology checks were reported as normal.
Assuming you judge the probability of a patient experiencing the most severe outcome
as "occasional," should the organization proceed with RCA2? (Hint: Refer to the Safety
Assessment Code Matrix.) - ANSWER-yes
RCA2 can be useful in health care because: - ANSWER-It helps to identify system
failures that can be corrected.
What is the ultimate purpose of conducting RCA2 after an adverse event? - ANSWER-
Taking action to reduce the risk of future harm
Which of the following scenarios would most likely call for RCA2? - ANSWER-A social
worker catches a patient who is falling out of bed
