Patient Safety II: RCA and FMEA Overview
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Questions and Answers

When should an investigation be initiated according to established protocols?

  • Only during the annual performance review of staff.
  • Once a month during safety meetings.
  • After an adverse event occurs or when there is a near miss. (correct)
  • Only after a routine check is performed.

    • What type of event requires an investigation without exception?

  • Minor errors in documentation.
  • Routine patient assessments.
  • Voluntary incident reports.
  • Sentinel events. (correct)

    • Under what circumstances might an investigation not be required?

  • Investigations are always required regardless of the situation. (correct)
  • Only after a sentinel event occurs.
  • During near misses only.
  • When standard protocols are met.

    • Which of the following scenarios is an example of when investigations should occur?

    <p>A near miss involving incorrect medication administration.</p> Signup and view all the answers

    What distinguishes sentinel events from other incidents?

    <p>They necessitate an investigation without exception.</p> Signup and view all the answers

    Which area should be prioritized for gathering information after an event occurs?

    <p>Close to the event occurrence</p> Signup and view all the answers

    What is the primary method used to identify the root cause of a problem?

    <p>Utilizing the '5 Whys' approach</p> Signup and view all the answers

    In the '5 Whys' method, how many times should the question 'Why' be asked to reach the root cause?

    <p>Five times</p> Signup and view all the answers

    What is a significant characteristic of the interview process after an event?

    <p>Interviewing individuals to gather diverse perspectives</p> Signup and view all the answers

    Which of the following best describes the focus when gathering information post-event?

    <p>Detailed accounts from individuals or written records</p> Signup and view all the answers

    What is the first step necessary for conducting an effective process study?

    <p>Including all individuals involved in the process</p> Signup and view all the answers

    How should the steps in a process flowchart be organized?

    <p>Numbered from top to bottom</p> Signup and view all the answers

    What is a crucial component when developing a flowchart of a process?

    <p>Ensuring that all steps are included</p> Signup and view all the answers

    Why is it important to include everyone involved in the process being studied?

    <p>To ensure diverse perspectives and insights</p> Signup and view all the answers

    What should the flowchart of a studied process depict?

    <p>All steps of the process in sequential order</p> Signup and view all the answers

    In which of the following situations should an investigation definitely occur?

    <p>After an adverse event occurs</p> Signup and view all the answers

    Which scenario would NOT typically prompt an investigation?

    <p>An adverse event follows established protocols</p> Signup and view all the answers

    What is a characteristic of investigations initiated after incidents?

    <p>They must happen immediately after every undesired event.</p> Signup and view all the answers

    What should be the primary focus of investigations following adverse events?

    <p>To determine the causes and prevent recurrence</p> Signup and view all the answers

    What best describes the timeframe for initiating investigations post-event?

    <p>Investigations are mandatory after every sentinel event without exception.</p> Signup and view all the answers

    What is the primary purpose of calculating the Risk Priority Number (RPN) in the FMEA process?

    <p>To identify which failure modes to address first</p> Signup and view all the answers

    How is the Risk Priority Number (RPN) calculated in the FMEA tool?

    <p>Likelihood of Occurrence × Severity × Likelihood of Detection</p> Signup and view all the answers

    What aspect distinguishes FMEA from RCA in the context of risk assessment?

    <p>FMEA is proactive while RCA is reactive</p> Signup and view all the answers

    In the FMEA process, what do 'Failure modes' refer to?

    <p>The possible ways in which a process could fail</p> Signup and view all the answers

    What is the significance of assessing 'Likelihood of Occurrence' in the FMEA process?

    <p>It evaluates how likely a failure is to happen</p> Signup and view all the answers

    Study Notes

    Patient Safety II

    • Dr. Shaima Hamed Albelwi is the quality & patient safety director at Tabuk healthcare affair.
    • She holds several qualifications including MD, MSC, CPHQ, CPPS, and FISQUA.
    • She is also a teamstepps master trainer and internal assessor of King Abdulaziz award.

    Content Outline

    • The presentation covers RCA (Root Cause Analysis).
    • It covers FMEA (Failure Mode and Effects Analysis).
    • It highlights the differences between RCA and FMEA.
    • It discusses healthcare organizations.

    Healthy Kidney Removed by Mistake 2015

    • A patient with suspected kidney cancer had the wrong kidney removed.
    • The healthy left kidney was removed instead of the right kidney that showed the suspected cancer.
    • A second surgery was performed to remove the right kidney.
    • The patient was left dependent on dialysis after losing both kidneys.
    • The patient was not a candidate for a kidney transplant.

    Root Cause Analysis - The Concept

    • Root cause analysis is used to identify the underlying causes of problems.
    • The problem is the obvious surface-level issue.
    • The source is the obscured underlying causes.
    • The process involves drilling down to find the root causes.

    Factors that are Root Causes

    • Culture & leadership
    • Technical support
    • Training
    • Clinical support
    • Staff shortages
    • Inexperienced team member
    • Failed to monitor vital signs
    • Poor team communication

    Root Cause Analysis (RCA)

    • RCA is an approach, tools, and techniques for determining the root cause of a problem.
    • It involves a structured process of problem identification, data collection, causal factor identification, and root cause identification.
    • Tools and techniques including 5 Whys analysis are usually used to analyze root causes.

    When and Where

    • RCA is performed after an adverse event or near miss and in the case of sentinel events.
    • RCA is performed close to the event occurrence.
    • RCA can involve individual interviews.

    How to Conduct RCA

    • The 5 Whys method is utilized, asking Why 5 times to identify root causes.
    • Ensure all aspects are completely analyzed and no loose ends remain.

    RCA Process Steps

    • Define the problem
    • Collect the data
    • Identify possible causal factors
    • Identify root causes
    • Recommend and implement solutions

    Sample Flowchart

    • The sample flowchart illustrates a standard procedure, involving steps 1 through 5, with a decision point (step 6A/6B) and a final step (step 6B).

    Fishbone Diagram

    • A fishbone diagram is a useful tool for analyzing the various sub-causes, categorizing in environments, people, equipment, processes, management, and materials.

    Multivoting

    • Multivoting is a method of gaining consensus by collecting votes from participants.

    Pareto Chart

    • Pareto charts are used to visualize data, in this case categories and quantities. Visualizing the relative importance of issues.

    Action Plan

    • An action plan template is used for planning solutions.
    • The template includes columns for the goal, how, who, when, measurables, resources, and completed status.

    Report and Evaluation

    • The findings from the RCA should be evaluated.
    • Report findings to relevant groups like administration and regulatory bodies.
    • The effectiveness of actions and efficiency of the RCA process should also be evaluated.

    Failure Mode and Effects Analysis (FMEA)

    • A tool used for proactively analyzing and evaluating a process.
    • FMEA identifies potential failure points and their impacts.
    • It determines the causes, effects, and likelihood of failure.
    • FMEA is used to identify the portion of the process that needs modification.

    Steps in FMEA

    • Identify the process
    • Establish an interdisciplinary team
    • Develop a flowchart of the process.
    • List potential failure modes
    • Determine the likelihood of occurrence, severity, and detection of each mode.
    • Rank failure modes by risk priority number (RPN)
    • Develop action plans for high-priority failure modes.

    FMEA Tool

    • The FMEA tool prompts teams to review, evaluate, and document steps and processes.
    • It includes failure modes (possible issues that can go wrong), failure causes (why issues happened), failure effects (the results of issues), and the probability of their occurrence, detection, and severity.

    Risk Priority Number (RPN)

    • A result of determining how likely issues are, how severe the issue would be, and likelihood of detecting it.
    • The likelihood of occurrence, likelihood of detection and severity are multiplied to generate this number.

    FMEA vs RCA

    • FMEA is proactive, identifying potential issues before they happen.
    • RCA is reactive, analyzing issues that have already happened.

    WHO Surgical Safety Checklist

    • In 2009, WHO developed a 19-item surgical safety checklist.
    • The checklist aims to decrease errors and adverse events during surgery. Specific items include pre-anesthesia and pre-skin incision checks as well as post-procedure checks.

    National Quality Forum (NQF)

    • NQF's role includes identifying a core list of preventable events, such as medication errors, healthcare-associated infections, falls, pressure ulcers, and surgical complications.
    • It includes measures to increase safety in these areas.

    Centers for Medicare and Medicaid Services (CMS)

    • CMS started withholding Medicare reimbursement in October 2008 for 10 healthcare-acquired conditions.
    • Conditions unrelated to admission, developed during hospital stay.

    Joint Commission

    • In 2003, the Joint Commission established National Patient Safety Goals.
    • Other organizations followed suit and created safety goals, including those for International Patient Safety.

    AHRQ Patient Safety Indicators

    • A set of risk-adjusted measures for hospital complications and adverse events.
    • This includes indicators on the hospital and area level.

    Institute for Healthcare Improvement (IHI)

    • IHI aims to establish safety measures and early warning systems for patients to receive the safest care.
    • This approach involves creating system-level changes in healthcare organizations.

    Patient Safety and Quality Improvement Act of 2005

    • The PSQIA established Patient Safety Organizations (PSOs) for standardizing data collection on adverse events.
    • It focused on data collection, reporting, and no fear of legal actions, approved by the Agency for Healthcare Research and Quality (AHRQ).

    Additional Notes

    • Further exploration of the subjects is recommended for better comprehension.
    • Translation of Arabic text is provided.
    • Updated the notes to include information from the supplied text.

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    Related Documents

    Patient Safety II Presentation PDF

    Description

    This quiz explores concepts of patient safety with a focus on Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA). Delve into the differences between these methodologies and their applications in healthcare organizations. Gain insights from real-life cases, including surgical errors and their implications for patient care.

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