Root Cause Analysis

Question 1

What are the four types of error?

Answer 1

Slips (commission) - failures of attention (incorrect action)
Lapses (omission) - failure of memory
Mistakes - rule based or knowledge based (plan not correct for reaching the goal)
Violations - intentional and deliberate violation of a procedure or norm

Question 2

What are the two types of adverse events?

What is the difference between these?

Answer 2

Patient safety incident
Never event

Whether it’s serious, preventable or needed measures to be in place.

Question 3

What type of error does root cause analysis look to identify?

Name 3 methods of root cause analysis.

Answer 3

Latent conditions

Fishbone diagram
5 Whys
Timelines

Question 4

Describe the 5 why method.

Give three factors taken into account in Fishbone Diagram.

Answer 4

What is the specific problem?
Why did it occur?
Why again

Patient factors
Individual (staff) factors
Task factors

Question 5

Describe timeline mapping.

Answer 5

Right timeline of what actually happened and compared to timeline of what should have happened if policy and clinical guidelines were followed.

Then identify any variations from acceptable practice

Question 6

Give a sequence of things that will occur if a PSI occurs.

Answer 6

DATIX reporting of incidence
RCA investigation occurs
Final report made in 60 days and sent to comissioners
They have to review it and send it back in 20 days

Question 7

What is the deming cycle?

Give another continuous improvement approach.

Answer 7

Continous quality improvement model consisting of a logical sequence of four repetitive stepsfor continuous improvement and learning.

Plan DO CHECK(study) ACT

A3 thinking