PATIENT SAFETY IHI PS 201 ROOT CAUSE ANALYSES AND ACTIONS PRACTICE EXAM NEW SOLUTION GUIDE

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PATIENT SAFETY: IHI PS 201 ROOT CAUSE ANALYSES AND ACTIONS PRACTICE EXAM NEW SOLUTION GUIDE RCA2 can be useful in health care because: (A) It holds people accountable for their actions. (B) It helps to identify system failures that can be corrected. (C) It helps to assess the potential risk of introducing a new idea or process. (D) All of the above - B RCA2 makes health care safer by focusing on systems failures and improving processes. It does not blame individuals for their actions and is not a method for enforcing accountability. It is not a method for assessing the risk of introducing a new idea or process. Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. An RCA2 team is exploring what happened. They consider characteristics of the patient and staff members. According to Charles Vincent, what other areas should they consider? (A) Team factors (B) Work environment (C) Institutional context (D) All of the above - D The best answer is all of the above. A wide range of factors influence medical outcomes. Charles Vincent lists seven categories these factors, including: patient characteristics, task factors, individual staff member characteristics, team factors, work environment, organizational and management factors, and institutional context. Which of the following scenarios would most likely call for RCA2?

(A) An occupational therapist quits after only three days on the job. (B) A physician is convinced that there is a better way to deliver pain medications on her unit. (C) A social worker catches a patient who is falling out of bed. (D) An administrator needs to develop a balanced budget. - C RCA2 is important to address adverse events as well as near misses, such as the near-fall in answer choice C, that indicate a potential for harm to patients. Although the other options may represent opportunities for improvement, they are not indicative of an imminent threat to patient safety and would not trigger RCA2. In regard to RCA2, "The chance of a specific event occurring; measured in terms of consequences and likelihood" is the definition of: (A) Quality (B) Risk (C) Safety (D) Hazard - B This is a description of risk. As opposed to harm-based prioritization, RCA2 recommends using risk-based prioritization for responding to adverse events. Which of the following is a helpful tool/method for identifying underlying causes of problems? (A) 'Five whys' exercise (B) Cause and effect diagram (C) Harm-based prioritization matrix (D) A and B - D Cause and effect diagrams and the 'Five Whys' exercise are useful tools to determine the root cause of a problem. The Safety Assessment Code Matrix is a method for determining which adverse events warrant close investigation. What is the ultimate purpose of conducting RCA2 after an adverse event?

(A) Doing a complete and thorough reconstruction of what happened before the event (B) Defining what should have happened for the patient (C) Creating a complete cause and effect diagram (D) Taking action to reduce the risk of future harm - D After you identify a safety problem within your system, the only way to make the system safer and prevent future harm is by taking action. This is the ultimate goal of RCA2. The other answer options are steps along to way toward this ultimate goal. Quinn is a three-year-old boy with a congenital heart malformation. While recovering in the pediatric intensive care unit after surgical correction, he is accidentally given ten times the appropriate dose of heparin. Although he suffers no permanent injuries, the leaders of the hospital decide to conduct a RCA2. As they assemble the team, which of the following would you recommend? (A) Include Quinn's parents. (B) Put together a team that mostly includes nurses and physicians. (C) Create a team of members who fulfill several roles. (D) Include the health care providers involved in Quinn's care. - C RCA2 teams need to be diverse in order to be able to see as many viewpoints as possible. The patient and family, as well as the providers, involved in the event should not be included in the RCA2 teams, although they should be kept informed of the progress. Interprofessional teams are strongly encouraged, but there is no hard-and-fast prescription for which professions should be included or what the balance of the professions should be. Ideally, the team will include people with a strong understanding of the areas and processes involved in the case. What should leadership teams do to support the RCA2 process? (A) Make sure there is at least one member of senior leadership on the team. (B) Wait to conduct the RCA2 review for at least 30 days, to let the emotions surrounding the incident subside. (C) Make sure the RCA2 team has designated time to conduct a thorough review. (D) All of the above - C

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Conducting a high-quality RCA2 review takes time, and leadership needs to ensure team members have time to devote to RCA2 tasks as part of their work. Senior leadership does not need to be on the core investigative team; in fact, senior leaders may be an impediment to drawing candid answers out of front-line staff. RCA2 activities should be conducted quickly, before memories fade and attention is turned to newer problems. Which of the following is a method for identifying underlying causes of specific problems? (A) 'Five whys' exercise (B) Swiss cheese model of accident causation (C) Asking people in the system via 1:1 interviews why they believe an event occurred (D) All of the above - A The 'five whys' exercise is a useful tool to help teams get to the root causes of problems by persistently asking "why?". Effective interview questions focus on identifying what happened, not why. The Swiss cheese model is a conceptual framework that is helpful to keep in mind as you explore cause and effect but is not itself an investigative method. Which of the following is one of the Five Rules of Causation? (A) Some effects have no identifiable cause. (B) Human error must have a preceding cause. (C) Failure to follow procedure is often a root cause. (D) In a hazardous environment, people have a responsibility to act safely. - B The Five Rules of Causation include: 1) Clearly show the cause and effect relationship. 2) Use specific and accurate descriptors for what occurred. 3) Human error must have a preceding cause. 4) Violations of procedure are not a cause, but must have a preceding cause. 5) Failure to act is only causal when there is a pre-existing duty to act.

An RCA2 team is launching an investigation of a surgical error. If they complete an effective review, which of the following is an example of a root cause they might identify? (A) The surgeon did not listen to the nurse. (B) The patient was male. (C) The hierarchy in the operating room had a negative effect upon communication. (D) All of the above - C RCA2 is meant to identify system failures that place patients at risk. Poor communication due to hierarchy is an example of an inherent problem in the system that could cause it to fail. If the surgeon failed to listen to the nurse, it would be a symptom of this larger problem. Which of the following is a recommendation for effective interviewing during RCA2? (A) Avoid writing questions ahead of time to keep an open mind. (B) The entire RCA2 team should be present at each interview to hear first-hand accounts. (C) Set the right tone by expressing your own regret about what happened. (D) Speculate why you personally believe the incident occurred. - C RCA2 interviews are often emotional and require sensitivity. To set the right tone for the interview, especially with a patient or family member, it is appropriate to express your regret that an unfortunate outcome or near miss occurred. However, do not speculate at this point what caused the incident. Each interview should involve only one or two RCA2 team members. Ideally, the team should work together to prepare the interview questions ahead of time. Which is the following is an example of an engineering control (forcing function)? (A) Require quiet for nurses when they are programming medication pumps. (B) Implement computer alerts for drug-drug interactions. (C) Use two nurses to independently calculate high-risk medication dosages.

(D) Change the design of equipment so that cords can't connect to the wrong machine (i.e., they won't fit). - D Changing the design of equipment to make it impossible to do the wrong thing is an example of a forcing function, a strong action to reduce the chances of an error or adverse event. The other options represent intermediate actions for improving safety: eliminating distractions, implementing software enhancements, and adding redundancy. Which of the following types of interventions is likely to be most effective for improving safety? (A) Increasing staffing (B) Conducting additional training (C) Posting warning signs (D) Standardizing processes - D The best answer is standardizing processes. All of these types of interventions can help improve safety, but things like adding staff, trainings, or signs are not usually as effective as truly changing the process. The goals of measuring effectiveness, an important step in the RCA2 process, include: (A) Ensuring there's been compliance with the action items (B) Evaluating the effectiveness of the action items (C) Determining whether further corrective action is needed (D) All of the above - D The best answer is all of the above. Process measures confirm the action has been implemented, while outcome measures tell you if the action was effective. Both are necessary and will help inform improvers if their changes are sufficient or further action is warranted. Warning signs of an ineffective RCA2 include: (A) Human error is identified as causing the event.

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(B) Multiple corrective actions are identified. (C) The event review took longer than 25 days to complete. (D) All of the above - A If human error is identified as causing the event, the RCA2 was not conducted properly. The Five Rules of Causation state that human error must always have a preceding cause. Reviews may take up to 45 days and often yield several recommendations for action. 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 have a specific method to make sure they reach all patients with INRs and communicate abnormal results and associated updates to their plan of care. Which of the following is the best recommended action statement? (A) The nurse in charge of calling patients with their results should be replaced. (B) With a goal of 99% of patients receiving calls within 2 days of their results: Have the phlebotomy lab automatically generate a list of all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with the results. (C) Patients awaiting lab results should be given access to MyChart, a part of the electronic health record that allows them to access their lab results themselves. (D) Patients need to have their INRs checked more frequently. - B Effective recommendations for action contain ideas for improving the system as well as ideas for measurement. Answer B has both of these characteristics. A is punitive and not systems-based, and C does not directly address the problem of the lack of follow-up by the clinic. D, although a good idea, does not contain a measurable outcome.

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