Examples may include, but are not limited to: Boredom Failure to follow established policies/procedures Fatigue Inability to focus on task Inattentional blindness/ confirmation bias Personal problems Lack of complex critical thinking skills Rushing to complete task Substance Trust 4 How did the equipment Consider all medical equipment and devices performance affect the used in the course of patient care, including outcome? AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. In your discussion, provide information on the following, as applicable: Descriptions of biomedical checks Availability and condition of equipment Descriptions of equipment with multiple or removable pieces Location of equipment and its accessibility to staff and patients Staff knowledge of or education on equipment, including applicable competencies Correct calibration, setting, operation of alarms, displays, and controls 5 What controllable What environmental factors within the environmental factors organization’s control affected the outcome? directly affected this Examples may include, but are not limited outcome? to: Overhead paging that cannot be heard Safety or security risks Risks involving activities of visitors
Examples may include, but are not limited to: Boredom Failure to follow established policies/procedures Fatigue Inability to focus on task Inattentional blindness/ confirmation bias Personal problems Lack of complex critical thinking skills Rushing to complete task Substance Trust 4 How did the equipment performance affect the outcome? Consider all medical equipment and devices used in the course of patient care, including AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. In your discussion, provide information on the following, as applicable: Descriptions of biomedical checks Availability and condition of equipment Descriptions of equipment with multiple or removable pieces Location of equipment and its accessibility to staff and patients Staff knowledge of or education on equipment, including applicable competencies Correct calibration, setting, operation of alarms, displays, and controls 5 What controllable environmental factors directly affected this outcome? What environmental factors within the organization’s control affected the outcome? Examples may include, but are not limited to: Overhead paging that cannot be heard Safety or security risks Risks involving activities of visitors
RCA_Questions_Framework.docx