IHI PS 103: Root Cause and Systems Analysis Study Guide (2025/2026)
Course Description: This course teaches the foundational methods for investigating a
patient safety event, including understanding the key concepts of a Just Culture,
performing a rigorous root cause analysis (RCA), and developing effective actions to
prevent future harm.
Module 1: Introduction to Root Cause Analysis
1. What is the primary goal of a Root Cause Analysis (RCA)?
ANSWER ✓ The primary goal is not to assign blame to an individual, but to understand
the underlying system-level factors that contributed to an adverse event and to identify
sustainable actions to prevent its recurrence.
2. According to a Just Culture model, what is the appropriate response to a human
error?
ANSWER ✓ Console the individual. Human errors are unintentional and often result
from system design flaws. The response should be to comfort the staff member and
improve the system to make errors less likely.
3. In a Just Culture, what is the appropriate response to at-risk behavior?
ANSWER ✓ Coach the individual. At-risk behavior occurs when a person chooses an
action that increases risk but is unaware of the potential negative outcome. Coaching
helps them understand the risk.
4. In a Just Culture, what is the appropriate response to reckless behavior?
, ANSWER ✓ Punish (or discipline) the individual. Reckless behavior is a conscious
disregard of a substantial and unjustifiable risk. It is a behavioral choice, not a system
issue.
5. What are the four main principles of a Just Culture?
ANSWER ✓ 1) Acknowledge that human error is inevitable and systems should be
designed to mitigate it. 2) Create a non-punitive environment for reporting errors and
near misses. 3) Use a systematic process to differentiate between human error, at-risk
behavior, and reckless behavior. 4) Hold individuals accountable for the quality of their
choices, not for their human errors.
6. Why is it critical to involve frontline staff in an RCA?
ANSWER ✓ Frontline staff have the most direct knowledge of the processes,
workarounds, and system vulnerabilities that led to the event. Their input is essential for
identifying true root causes and feasible solutions.
7. What is the difference between a latent error and an active error?
ANSWER ✓ An active error is an error that occurs at the point of contact by a frontline
person (e.g., administering the wrong drug). A latent error (or latent condition) is a
hidden flaw in the system that lies dormant until it contributes to an event (e.g., look-
alike drug packaging, poor lighting, understaffing).
8. What is a "second victim"?
ANSWER ✓ It refers to the healthcare providers who are involved in an unanticipated
adverse patient event and who themselves experience significant psychological and
emotional trauma as a result.
9. What is the first step that should be taken immediately after a serious safety
event is identified?
, ANSWER ✓ Ensure the immediate safety and care of the patient involved.
10. What is the purpose of an "initial briefing" at the start of an RCA?
ANSWER ✓ To assemble the RCA team, define the roles, review the event based on
known facts, and establish a plan and timeline for the investigation.
Module 2: The RCA Process: From Triggering to Causation
11. What types of events typically trigger an RCA?
ANSWER ✓ Sentinel events, serious safety events (e.g., death, permanent harm), and
sometimes significant near misses with high potential for harm.
12. What is the first formal step of conducting an RCA after the team is
assembled?
ANSWER ✓ To create a clear, concise, and factual statement of what happened (the
"What, Who, When, Where").
13. Why is it important to create a chronology or timeline of the event?
ANSWER ✓ It helps the team establish an objective, sequential account of the event,
identify discrepancies in the process, and pinpoint where the system failed.
14. What is the difference between the "What" and the "Why" in an RCA?
ANSWER ✓ The "What" describes the sequence of events and the specific error that
occurred. The "Why" involves digging deeper to uncover the underlying system-based
reasons why that error was able to happen.
15. What is the "Five Whys" technique?
Course Description: This course teaches the foundational methods for investigating a
patient safety event, including understanding the key concepts of a Just Culture,
performing a rigorous root cause analysis (RCA), and developing effective actions to
prevent future harm.
Module 1: Introduction to Root Cause Analysis
1. What is the primary goal of a Root Cause Analysis (RCA)?
ANSWER ✓ The primary goal is not to assign blame to an individual, but to understand
the underlying system-level factors that contributed to an adverse event and to identify
sustainable actions to prevent its recurrence.
2. According to a Just Culture model, what is the appropriate response to a human
error?
ANSWER ✓ Console the individual. Human errors are unintentional and often result
from system design flaws. The response should be to comfort the staff member and
improve the system to make errors less likely.
3. In a Just Culture, what is the appropriate response to at-risk behavior?
ANSWER ✓ Coach the individual. At-risk behavior occurs when a person chooses an
action that increases risk but is unaware of the potential negative outcome. Coaching
helps them understand the risk.
4. In a Just Culture, what is the appropriate response to reckless behavior?
, ANSWER ✓ Punish (or discipline) the individual. Reckless behavior is a conscious
disregard of a substantial and unjustifiable risk. It is a behavioral choice, not a system
issue.
5. What are the four main principles of a Just Culture?
ANSWER ✓ 1) Acknowledge that human error is inevitable and systems should be
designed to mitigate it. 2) Create a non-punitive environment for reporting errors and
near misses. 3) Use a systematic process to differentiate between human error, at-risk
behavior, and reckless behavior. 4) Hold individuals accountable for the quality of their
choices, not for their human errors.
6. Why is it critical to involve frontline staff in an RCA?
ANSWER ✓ Frontline staff have the most direct knowledge of the processes,
workarounds, and system vulnerabilities that led to the event. Their input is essential for
identifying true root causes and feasible solutions.
7. What is the difference between a latent error and an active error?
ANSWER ✓ An active error is an error that occurs at the point of contact by a frontline
person (e.g., administering the wrong drug). A latent error (or latent condition) is a
hidden flaw in the system that lies dormant until it contributes to an event (e.g., look-
alike drug packaging, poor lighting, understaffing).
8. What is a "second victim"?
ANSWER ✓ It refers to the healthcare providers who are involved in an unanticipated
adverse patient event and who themselves experience significant psychological and
emotional trauma as a result.
9. What is the first step that should be taken immediately after a serious safety
event is identified?
, ANSWER ✓ Ensure the immediate safety and care of the patient involved.
10. What is the purpose of an "initial briefing" at the start of an RCA?
ANSWER ✓ To assemble the RCA team, define the roles, review the event based on
known facts, and establish a plan and timeline for the investigation.
Module 2: The RCA Process: From Triggering to Causation
11. What types of events typically trigger an RCA?
ANSWER ✓ Sentinel events, serious safety events (e.g., death, permanent harm), and
sometimes significant near misses with high potential for harm.
12. What is the first formal step of conducting an RCA after the team is
assembled?
ANSWER ✓ To create a clear, concise, and factual statement of what happened (the
"What, Who, When, Where").
13. Why is it important to create a chronology or timeline of the event?
ANSWER ✓ It helps the team establish an objective, sequential account of the event,
identify discrepancies in the process, and pinpoint where the system failed.
14. What is the difference between the "What" and the "Why" in an RCA?
ANSWER ✓ The "What" describes the sequence of events and the specific error that
occurred. The "Why" involves digging deeper to uncover the underlying system-based
reasons why that error was able to happen.
15. What is the "Five Whys" technique?
