Transcription of Root Cause Analysis (RCA) - ISMP Canada
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Root Cause Analysis (RCA) - ISMP Canada
root Cause Analysis (RCA) root Cause Analysis (RCA)Sylvia Hyland, Sylvia Hyland, BScPhmBScPhmJulie Julie GreenallGreenall, , BScPhmBScPhm I should have read the label. I should have read the label. This has not happened before. This has not happened before. This is unlikely to happen again. This is unlikely to happen again. Physician who reported a medication errorPhysician who reported a medication errorMedication Error ResponseMedication Error Response Thank you for helping me fulfill my moral obligation Thank you for helping me fulfill my moral obligationto the patient s family - my promise to the patient sto the patient s family - my promise to the patient swife to share the information with others so thatwife to share the information with others so thatsteps can be taken to try to prevent the same errorsteps can be taken to try to prevent the same errorfrom happening again. from happening again. Physician who reported a medication errorPhysician who reported a medication errorMedication Error ResponseMedication Error ResponseThe definition of an error is that it isThe definition of an error is that it to Believe:Need to Believe:Each human error must have aEach human error must have apreceding Cause .
Conducting a RCA and Developing an Action Plan • Define the team (small groups and individuals for consultation) • Define the problem exactly • Study the problem • Determine what exactly happened • Identify proximate and underlying causes • Confirm the causes through consultation
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