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PS 201: ROOT CAUSE ANALYSES AND ACTIONS QUESTIONS AND ANSWERS
  • Exam (elaborations)

    PS 201: ROOT CAUSE ANALYSES AND ACTIONS QUESTIONS AND ANSWERS

  • PS 201: ROOT CAUSE ANALYSES AND ACTIONS QUESTIONS AND ANSWERSPS 201: ROOT CAUSE ANALYSES AND ACTIONS QUESTIONS AND ANSWERSPS 201: ROOT CAUSE ANALYSES AND ACTIONS QUESTIONS AND ANSWERSa 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 p...
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PS 201: Root Cause Analyses and Actions Questions & Answers
  • Exam (elaborations)

    PS 201: Root Cause Analyses and Actions Questions & Answers

  • a systems approach to error asks: - "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 - - 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. co...
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PS 201: Root Cause Analyses and Actions
  • Exam (elaborations)

    PS 201: Root Cause Analyses and Actions

  • 1. A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. He goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA2. One root cause the team identifies is that the cardiology clinic does not ha...
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