Public Health

Question 1

What is Root Cause Analysis?

Answer 1

• Uses records and participant interviews to identify all the underlying problems that led to an error
• Categories include process, people, environment, equipment, materials and management.
• It is a retrospective approach applied after the failure has occurred in order to prevent its recurrence

Question 2

What is failure mode and effects analysis?

Answer 2

• Uses inductive reasoning to identify all the ways a process might fail and prioritize these by their probability of occurrence and impact on patients
• Future looking approach applied before process implementation to prevent failure occurrence.

Question 3

What types of medical errors can occur and what should be done?

Answer 3

Errors may involve patient identification, diagnosis, monitoring, nosocomial infection, medications, procedures, devices, documentation and handoffs.
- All errors, wether they cause harmful outcomes or not, should be disclosed to patients with an apology and within a timely manner.

Question 4

What is an active error?

Answer 4

Error that occurs at the frontline operator

• Ex. wrong IV pump dose programmed
• Has immediate impact

Question 5

What is a latent error?

Answer 5

Error that occurs in process indirect from operator but impacts patient care.

• Ex. different types of IV pumps used within the same hospital
• Accident waiting to happen