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Root cause analysis (PS58) (Indication (If a sentinel event occurs = clear…
Root cause analysis (PS58)
Definition
Analysis of what happened, why it happened, what can be done to prevent it
Performed by a team of clinicians, risk managers
Indication
If a sentinel event occurs = clear cut event that occurs independentely of a patient's condition, reflects system and process deficiencies, and results in unnecessary patient outcomes
Wrong body part
Suicide on inpatient ward
Retained instrument post sx
Gas embolus resulting in death/neuro injury
Blood tx reaction (ABO incomp)
Medical error leading to patient death
Maternal death / serious morbidity associated with labour or delivery
Barrier analysis
Looks at the control methods in place to prevent error
Physical barrier - lock things in cupboard
Natural barriers (temporal/distance) - waiting between 2 similar test so dont mix patients up, locking IV K up with controlled drugs
Human barriers - checking blood before transfusion
Admin barriers - Protocols, supervision, training
Human and admin barriers are weak as they are prone to error