Unit 1 Lesson 6: Causes and Reporting

Question 1

When an adverse event happens, healthcare workers need to report this. What is a adverse event?

Answer 1

an unexpected problem that occurs during treatment

Question 2

What is just culutre

Answer 2

a just culture allows for balanced accountability between individuals and organizations.

Question 3

wha thappens in just culture

Answer 3

A just culture distinguishes between human error (slips), at-risk behavior (taking shortcuts), and reckless behavior (ignoring required safety steps). In a just culture, at-risk and reckless behavior is punished even if it does not result in an error. O

Question 4

When an error or a near-miss occurs, you need to figure out how to keep it from happening again. The method used by many organizations, including healthcare facilities, is

Answer 4

root cause analysis (RCA)

Question 5

root cause analysis (RCA)

Answer 5

root cause analysis (RCA), a structured method to analyze and respond to adverse events.

Question 6

What is the goal of root cause analysis (RCA)

Answer 6

The ultimate goal of RCA is to prevent future problems, making this an integral part of the safety planning for an organization.

Question 7

How to use root casue analysis

Answer 7

Using root cause analysis, the first step is to identify what happened, how it happened, and why it happened through a systematic analysis of the event. The focus is on why the mistake happened, not who to blame, keeping in mind that most problems have more than one root cause. Once the causes are identified, actions and process changes that will prevent future errors can be identified. Once implemented, these new processes or systemic or physical changes should be a more permanent solution, rather than solving problems by constantly “putting out fires.”