PS 201: ROOT CAUSE AND SYSTEMS
ANALYSIS EXAM QUESTIONS AND
ANSWERS
Root cause analyses can be useful in health care because:
(A) They help to assign blame.
(B) They help to identify system failures that can be corrected.
(C) They are often quick and simple to perform. - ANSWER-(B) They help to identify
system failures that can be corrected.
Use the following scenario to answer questions 2 and 3:
Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left
ankle was operated upon rather than his right ankle.
The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis
(RCA) of the incident. If they complete a high-quality RCA, which of the following is an
example of the kind of root cause they might identify?
(A) The nurse did not listen to the patient.
(B) The patient was male.
(C) The hierarchy in the operating room had a negative effect upon communication.
(D) In this particular case, there was nothing that anyone on the surgical team could
have done to prevent an error such as this one. - ANSWER-(C) The hierarchy in the
operating room had a negative effect upon communication.
The team conducting the RCA of the wrong-site surgery realizes that one contributing
factor was the pressure on surgical teams to start and end surgeries on time (so as not
to disrupt later scheduled procedures). Which of Vincent's seven categories of factors
influencing clinical practice does this best illustrate?
(A) Patient characteristics
(B) Team factors
(C) Individual team member
(D) Organizational and management factors - ANSWER-(D) Organizational and
management factors
Which of the following scenarios would call for a root cause analysis?
(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) A social
worker catches a patient who is falling out of bed.
, Which is an important approach when conducting an RCA?
(A) Use categories to organize events that led to errors.
(B) Focus on a single process in order to consider it in depth.
(C) Consider the costs involved in addressing the problems found during the process.
(D) Avoid focusing on patterns. - ANSWER-(A) Use categories to organize events that
led to errors.
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 a
tenfold dose of heparin. Although he suffers no permanent injuries, the leadership of the
hospital rightly decides to conduct a root cause analysis. As they assemble the team, it
is crucial that they do the following:
(A) Include Quinn's parents.
(B) Put together a team of mostly nurses and physicians.
(C) Create a team of members who fulfill several roles.
(D) Include the health care providers involved in Quinn's care. - ANSWER-(C) Create a
team of members who fulfill several roles.
What else should the leadership do as they plan for the RCA?
(A) Wait to conduct the RCA for a period of time, in order to let the emotions
surrounding the incident subside.
(B) Make sure that the team conducting the RCA is clear about what they can and
cannot review from the records.
(C) Make sure the team has time and resources to conduct the RCA, including access
to advisors when necessary.
(D) Make sure there is at least one member of the senior leadership on the team. -
ANSWER-(C) Make sure the team has time and resources to conduct the RCA,
including access to advisors when necessary.
The RCA team working on Peter's case develops several recommended actions. Which
of the following is likely to have the strongest impact?
(A) Assign more staff to the job of calling patients with their INR results.
(B) Post signs reminding the staff to call patients with their INR results.
(C) Work with the phlebotomy lab to automatically generate the names of all patients
who had INRs drawn that day and send them in an email to the nurse responsible for
patient follow-up.
(D) Create a policy that specifies that patients with INRs must be called with their
results within one week. - ANSWER-(C) Work with the phlebotomy lab to automatically
generate the names of all patients who had INRs drawn that day and send them in an
email to the nurse responsible for patient follow-up.
The RCA team prepares and shares a summary of their work. What should it contain?
(A) A clear description of what happened, root causes, and recommendations for
prevention. Team members and methods should be included.
(B) A clear description of what happened, root causes, and recommendations for
prevention. Estimated costs for implementation should be included.
ANALYSIS EXAM QUESTIONS AND
ANSWERS
Root cause analyses can be useful in health care because:
(A) They help to assign blame.
(B) They help to identify system failures that can be corrected.
(C) They are often quick and simple to perform. - ANSWER-(B) They help to identify
system failures that can be corrected.
Use the following scenario to answer questions 2 and 3:
Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left
ankle was operated upon rather than his right ankle.
The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis
(RCA) of the incident. If they complete a high-quality RCA, which of the following is an
example of the kind of root cause they might identify?
(A) The nurse did not listen to the patient.
(B) The patient was male.
(C) The hierarchy in the operating room had a negative effect upon communication.
(D) In this particular case, there was nothing that anyone on the surgical team could
have done to prevent an error such as this one. - ANSWER-(C) The hierarchy in the
operating room had a negative effect upon communication.
The team conducting the RCA of the wrong-site surgery realizes that one contributing
factor was the pressure on surgical teams to start and end surgeries on time (so as not
to disrupt later scheduled procedures). Which of Vincent's seven categories of factors
influencing clinical practice does this best illustrate?
(A) Patient characteristics
(B) Team factors
(C) Individual team member
(D) Organizational and management factors - ANSWER-(D) Organizational and
management factors
Which of the following scenarios would call for a root cause analysis?
(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) A social
worker catches a patient who is falling out of bed.
, Which is an important approach when conducting an RCA?
(A) Use categories to organize events that led to errors.
(B) Focus on a single process in order to consider it in depth.
(C) Consider the costs involved in addressing the problems found during the process.
(D) Avoid focusing on patterns. - ANSWER-(A) Use categories to organize events that
led to errors.
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 a
tenfold dose of heparin. Although he suffers no permanent injuries, the leadership of the
hospital rightly decides to conduct a root cause analysis. As they assemble the team, it
is crucial that they do the following:
(A) Include Quinn's parents.
(B) Put together a team of mostly nurses and physicians.
(C) Create a team of members who fulfill several roles.
(D) Include the health care providers involved in Quinn's care. - ANSWER-(C) Create a
team of members who fulfill several roles.
What else should the leadership do as they plan for the RCA?
(A) Wait to conduct the RCA for a period of time, in order to let the emotions
surrounding the incident subside.
(B) Make sure that the team conducting the RCA is clear about what they can and
cannot review from the records.
(C) Make sure the team has time and resources to conduct the RCA, including access
to advisors when necessary.
(D) Make sure there is at least one member of the senior leadership on the team. -
ANSWER-(C) Make sure the team has time and resources to conduct the RCA,
including access to advisors when necessary.
The RCA team working on Peter's case develops several recommended actions. Which
of the following is likely to have the strongest impact?
(A) Assign more staff to the job of calling patients with their INR results.
(B) Post signs reminding the staff to call patients with their INR results.
(C) Work with the phlebotomy lab to automatically generate the names of all patients
who had INRs drawn that day and send them in an email to the nurse responsible for
patient follow-up.
(D) Create a policy that specifies that patients with INRs must be called with their
results within one week. - ANSWER-(C) Work with the phlebotomy lab to automatically
generate the names of all patients who had INRs drawn that day and send them in an
email to the nurse responsible for patient follow-up.
The RCA team prepares and shares a summary of their work. What should it contain?
(A) A clear description of what happened, root causes, and recommendations for
prevention. Team members and methods should be included.
(B) A clear description of what happened, root causes, and recommendations for
prevention. Estimated costs for implementation should be included.
