Incident Investigation and Analysis Flashcards

An incident investigation team is applying James Reason's "Swiss Cheese Model" of accident causation to analyze a medication error. In this model, what do the "holes" in the slices of cheese represent?

Answer: Latent failures or weaknesses in the organization's layers of defense.

In the Swiss Cheese Model, the slices of cheese are the organization's defenses and safeguards (e.g., policies, technologies, training). The holes represent latent conditions or hidden weaknesses within those defenses. An accident occurs when the holes in multiple defensive layers momentarily align, allowing a hazard to result in patient harm.

A safety officer is interviewing a nurse immediately following a patient fall. To ensure an effective and unbiased investigation that supports a Just Culture, which interview approach is MOST appropriate?

Answer: Asking open-ended, non-leading questions such as, "Can you walk me through what happened from your perspective?"

Open-ended, non-leading questions encourage a narrative account of the event without assigning premature blame. This approach is crucial for uncovering system factors and latent conditions. Asking a direct "why" question can sound accusatory, having a manager present can be intimidating and stifle open communication, and focusing only on individual actions ignores the broader system context.

Which of the following is the most significant benefit of systematically investigating and analyzing 'near miss' events in a healthcare setting?

Answer: It identifies and corrects system vulnerabilities before they cause patient harm.

The primary value of near miss analysis is its proactive nature. By investigating events where harm could have occurred but didn't, an organization can identify and fix latent system problems. This prevents similar circumstances from leading to an actual adverse event in the future. It is a cornerstone of a mature safety program.

According to The Joint Commission, an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof, is known as a:

Answer: Sentinel Event

The Joint Commission specifically defines a 'Sentinel Event' as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are so named because they signal the need for immediate investigation and response to identify and address the root causes and prevent recurrence.

A root cause analysis team is investigating a wrong-site surgery. They are brainstorming all conceivable factors and grouping them into categories such as People, Process, Equipment, and Environment. Which classic analysis tool are they MOST likely using?

Answer: Fishbone (Ishikawa) Diagram

The Fishbone or Ishikawa diagram is a visual tool used to explore and categorize the potential causes of a problem. It is structured with the problem (or effect) at the 'head' of the fish, and the major categories of causes (like People, Process, Equipment) as the 'bones,' allowing the team to brainstorm and organize contributing factors.

Following a root cause analysis of a retained surgical item, a corrective action plan is developed. Which of the following proposed actions is the STRONGEST and most effective?

Answer: Implementing a system where all sponges are tagged with RFID chips that are scanned before the patient leaves the OR.

This action represents an engineering control, which is high on the hierarchy of controls because it redesigns the system to make failure much more difficult, relying less on human memory and diligence. Retraining (A) and policy updates (D) are less effective administrative controls, and posters (B) are the weakest form of intervention (awareness).