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Flashcards in Pt Safe Deck (10):

Root Cause 6 steps

Gathering information about an incident
Mapping information
Identifying problems
Analysing problems for contributory factors
Determining root causes
Developing recommendations and implementing solutions


Clinical Governance

“A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish


Pt Safety

“The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.”


Medication Error

“Incident in which there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines advice, regardless of whether any harm occurred.” (NPSA, 2007; p9)


Never events

Unacceptable & eminently preventable”


Risk management techniques:

Failure Modes Effects Analysis


Risk management techniques:

Root Cause Analysis
GPhC recommends a root cause analysis (RCA) is undertaken on dispensing errors (GPhC, 2010)



“Systematic method of identifying and preventing process and product problems before they occur”

Step 1: Graphically describe process

Step 2: List failure modes (what could go wrong) for the process, rank the severity and probability of each failure mode

Step 3: List causes of failure modes

Step 4: Design interventions for failure modes

Step 5: Identify outcome measures for interventions

Step 6: Implement and monitor interventions


RCA definition

“a structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it.”


Reason’s Accident Causation Model is divided into 4

1. Latent failure - management and oraganisational
2. Error producing conditions eg. team factors
3. Unsafe acts - slips, lapses
4 Barriers overcome ---- incident