A hospital safety committee is reviewing a recent sentinel event in which a patient received an incorrect dose of a high-risk medication due to a misprogrammed infusion pump. The hospital administration initiates a formal root cause analysis (RCA) to investigate the incident and prevent future occurrences. Arrange the following fundamental steps of a root cause analysis in the correct chronological order of execution.
- 1Form a multidisciplinary team and gather comprehensive data regarding the incident.
- 2Construct a detailed timeline mapping the sequence of events leading up to the error.
- 3Identify the underlying latent system vulnerabilities and active failures.
- 4Develop and implement an action plan with targeted system-level interventions.
Cevap
The correct sequence for a root cause analysis is to first form a team and collect data, then construct a timeline of events, followed by identifying underlying system vulnerabilities, and finally developing an action plan.
Root cause analysis (RCA) is a retrospective, systems-based approach used to investigate sentinel events and prevent their recurrence. The standardized sequence ensures a thorough investigation rather than assigning individual blame. The correct chronological order is: 1) Form a multidisciplinary team and gather data, 2) Construct a timeline of events, 3) Identify underlying system vulnerabilities (root causes), and 4) Develop and implement an action plan.
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Anahtar Kavram
Root Cause Analysis (RCA) execution sequence