Data Analytics Flashcards
In root cause analysis what is assumed to be the problem People or process?
process drives outcomes!!
- within our control
- can be altered
What are the two variables we need to determine about an incident?
severity
probability
what two things make up the criteria for a sentinel event?
unexpected pt death
injury/incident that could lead to permanent change in function
Name as many potential sentinal events as you can
pt abduction, elopement, pt or caregiver assult or injury, MEDICATION ERROR (very common), care delivered by an unlicenced practitioner, medical procedure on wrong pt or incorrect procedure
What is a very common potential sentinel event?
medication error
What is the “definition” of a major event as it relates to injury to a pt.
incident leading to hospitalization
What are a couple examples of a major event?
fall w/injury that impacts function
theft
fire
equipment damage
What are the towo definitions of moderate event
potentially avoidable complication of an existing condition
fall or injury that does NOT impact function
What severity event would someones wound that gets infected?
moderate incident
what kind of event would it be if a pt had a fall and they ended up hospitalized because of it?
major incident
minor event is defined as what?
non injury or first aid tx
what is the timeline definition of frequent?
circumstances leading to incident occur at least monthly
What is the timeline definition of occasional?
circumstances leading to incident occur at least 1-2x per year
what is the timeline definition of uncommon?
potential to occur every 2-5 years
What is thetimeline definition of remote?
potential to occur is less than every 5 years
true or false probability takes into account how often something actually happens?
false! talk about how often do the circumstances exist that the issue is likely to occur in
What kind of events (in terms of severity and probability) would you for sure do a RCA on?
Frequent + sentinel (as well as possible sentinel)
Frequent + major
Occasional + sentinel (+ possible sentinel)
Occasional + major
What are the three major questions you have to ask when dconducting the RCA?
what happened (event, data collection, timeline, interview staff)
why did it happen (root cause, contributing factors)
what will prevent it from happening again (implement action plan, measure progress)
preliminary data collection is part of what question associated with conducting an RCA?
what happened
llisting all potneital “causal factors” contributing to an event is part of what question for conducting an RCA?
Why did it happen.
equipment/supplies
environmental
rules policies and procedures
people
are all categories of what?
Fishbone diagram for the “Why did it happen” portion of RCA
DMAIC and PDSA are part of what question of the RCA?
What will make sure it does not happen again
What does PDSA stand for?
plan
do
study
act
What does DMAIC stand for
define measure analyze improve control
