PS 201: ROOT CAUSE ANALYSES AND
ACTIONS QUESTIONS AND ANSWERS
a systems approach to error asks: - ANSWER-"What circumstances led a reasonable
person to make reasonable decisions that resulted in an undesirable outcome?"
This mindset is how to actually make systems safer.
latent errors/conditions - ANSWER-- pre-existing conditions in processes and systems
that set people up for failure (e.g., poor equipment design, inadequate training, or
insufficient resources).
- key component of James Reason's model of accident causation, the Swiss cheese
model.
contributing factors (or holes in the cheese) in AE but are NOT preventable - ANSWER-
Because Margaret has dementia, she may have had difficulty paying attention or
understanding what was happening.
Amy's lack of experience may have led her to make a decision that a more experienced
nurse wouldn't have made.
And Jorge might have taken more time to communicate effectively had he been less
busy.
Root cause analysis seeks to - ANSWER-delve deeper, to identify problems in the
system that people can actually fix, understand and respond to root causes to prevent
future harm
root cause - ANSWER-a latent vulnerability in a system that allows an error to occur
7 categories of contributory factors that influence clinical practice (Charles Vincent) -
ANSWER-Institutional context
Organizational and management factors
Work environment
Team factors
Individual staff members
Task factors
Patient characteristics
a cause and effect diagram or 'fishbone' diagram - ANSWER-tool that helps teams
identify contributory factors and visually group them
five whys was created by - ANSWER-Taiichi Ohno, father of the Toyota Production
System, which revolutionized automobile manufacturing with methods now known as
Lean.
, five whys exercise/analysis - ANSWER-asking 'why?' again and again until you reach
the root cause
five whys example - ANSWER-Why did the patient receive the wrong medication?
The nurse did not complete patient identification.
Why? The patient did not have a wristband.
Why? The wristband had been removed for a procedure and not replaced.
Why? The printer for the wristbands was not working.
Why? ROOT CAUSE: The staff needed to support IT had been reduced and was
overworked.
Five Whys Example: Mrs. Smith is an elderly patient with congestive heart failure,
admitted to hospital every 6 weeks. - ANSWER-• Why?
o Fluid in lungs causing shortness of breath
• Why?
o The sodium content was building up causing fluid retention
• Why?
o Patient was ingesting too much sodium or the diuretics weren't working well enough
• Why?
o Patient lacked the knowledge and support to manage her diet and drug regimen
• Why?
o ROOT CAUSE: Patient education process is ineffective and support systems don't
exist when they go home
safety assessment code matrix probability categories - ANSWER-• Probability
categories: frequent, occasional, uncommon, remote
Example of applying risk-based prioritization:
• A pacemaker failed to work, putting a patient in danger
• Repeated attempts to fix the pacemaker (turning it off and on) did not help
• Investigation revealed the same failure happened every 9 months - ANSWER-•
Catastrophic category, occasional (every 9 months): level 3, would get action
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.
1. You are evaluating whether an RCA2 should be performed on this event. What would
you say is the actual severity of this event?
a) Catastrophic
b) Major
c) Moderate
d) Minor.
ACTIONS QUESTIONS AND ANSWERS
a systems approach to error asks: - ANSWER-"What circumstances led a reasonable
person to make reasonable decisions that resulted in an undesirable outcome?"
This mindset is how to actually make systems safer.
latent errors/conditions - ANSWER-- pre-existing conditions in processes and systems
that set people up for failure (e.g., poor equipment design, inadequate training, or
insufficient resources).
- key component of James Reason's model of accident causation, the Swiss cheese
model.
contributing factors (or holes in the cheese) in AE but are NOT preventable - ANSWER-
Because Margaret has dementia, she may have had difficulty paying attention or
understanding what was happening.
Amy's lack of experience may have led her to make a decision that a more experienced
nurse wouldn't have made.
And Jorge might have taken more time to communicate effectively had he been less
busy.
Root cause analysis seeks to - ANSWER-delve deeper, to identify problems in the
system that people can actually fix, understand and respond to root causes to prevent
future harm
root cause - ANSWER-a latent vulnerability in a system that allows an error to occur
7 categories of contributory factors that influence clinical practice (Charles Vincent) -
ANSWER-Institutional context
Organizational and management factors
Work environment
Team factors
Individual staff members
Task factors
Patient characteristics
a cause and effect diagram or 'fishbone' diagram - ANSWER-tool that helps teams
identify contributory factors and visually group them
five whys was created by - ANSWER-Taiichi Ohno, father of the Toyota Production
System, which revolutionized automobile manufacturing with methods now known as
Lean.
, five whys exercise/analysis - ANSWER-asking 'why?' again and again until you reach
the root cause
five whys example - ANSWER-Why did the patient receive the wrong medication?
The nurse did not complete patient identification.
Why? The patient did not have a wristband.
Why? The wristband had been removed for a procedure and not replaced.
Why? The printer for the wristbands was not working.
Why? ROOT CAUSE: The staff needed to support IT had been reduced and was
overworked.
Five Whys Example: Mrs. Smith is an elderly patient with congestive heart failure,
admitted to hospital every 6 weeks. - ANSWER-• Why?
o Fluid in lungs causing shortness of breath
• Why?
o The sodium content was building up causing fluid retention
• Why?
o Patient was ingesting too much sodium or the diuretics weren't working well enough
• Why?
o Patient lacked the knowledge and support to manage her diet and drug regimen
• Why?
o ROOT CAUSE: Patient education process is ineffective and support systems don't
exist when they go home
safety assessment code matrix probability categories - ANSWER-• Probability
categories: frequent, occasional, uncommon, remote
Example of applying risk-based prioritization:
• A pacemaker failed to work, putting a patient in danger
• Repeated attempts to fix the pacemaker (turning it off and on) did not help
• Investigation revealed the same failure happened every 9 months - ANSWER-•
Catastrophic category, occasional (every 9 months): level 3, would get action
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.
1. You are evaluating whether an RCA2 should be performed on this event. What would
you say is the actual severity of this event?
a) Catastrophic
b) Major
c) Moderate
d) Minor.
