Root Cause Analysis Training - PowerPoint PPT Presentation
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Root Cause Analysis Training
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Equipment and resources- Possibly no/very basic IT systems-No safeguards in IT system ... Condition: Symptomatic anaemia* Hb 5.9 *-patient's condition possibly did not ... – PowerPoint PPT presentation
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Title: Root Cause Analysis Training
1
Framework of contributory factor influencing
clinical practice (Charles Vincent 1998)
CASE 2
2
Framework of contributory factor influencing
clinical practice (Charles Vincent 1998)
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Framework of contributory factor influencing
clinical practice (Charles Vincent 1998)
4
Other considerations when investigating incident
- Interviewing staff involved
- Statements
- Establish skill mix at time of incident examine
staff rotas - Review of hospital risk management data to see if
there are other similar incidents - Disclosure to patient of adverse event- how is
this managed?
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