Enhanced documentation, Highlight medication name and dose on IV bags. communication Weaker Actions Double checks One person calculates dosage, another person reviews their calculation. Warnings Add audible alarms or caution labels. (These tasks rely New procedure/ Remember to check IV sites every 2 hours. more on memorandum/policy humans to Training Demonstrate correct usage of hard-to-use medical equipment. remember to perform the task correctly) Reference: Action Hierarchy levels and categories are based on Root Cause Analysis Tools, VA National Center for Patient Safety, . Examples are provided here. National Patient Safety Foundation. Boston, MA: National Patient Source: RCA2 Improving Root Cause Analyses and Actions to Prevent Harm. Safety Foundation; 2015. Reproduced with permission. A-3. Measure of Success Fraction Part Defined Identified Example Numerator The number of Ask a specific Falls that resulted in hip fractures events being question—what are in diabetic patients over 70 years of measured you measuring? age Denominator All the opportunities Identify the patient The number of diabetic patients on in which the event population from a unit who are older than 70 years could have occurred which to collect the of age information.
Enhanced documentation, communication Highlight medication name and dose on IV bags. Weaker Actions (These tasks rely more on humans to remember to perform the task correctly) Double checks One person calculates dosage, another person reviews their calculation. Warnings Add audible alarms or caution labels. New procedure/ memorandum/policy Remember to check IV sites every 2 hours. Training Demonstrate correct usage of hard-to-use medical equipment. Reference: Action Hierarchy levels and categories are based on Root Cause Analysis Tools, VA National Center for Patient Safety, . Examples are provided here. Source: National Patient Safety Foundation. RCA2 Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Reproduced with permission. A-3. Measure of Success Fraction Part Defined Identified Example Numerator The number of events being measured Ask a specific question—what are you measuring? Falls that resulted in hip fractures in diabetic patients over 70 years of age Denominator All the opportunities in which the event could have occurred Identify the patient population from which to collect the information. The number of diabetic patients on a unit who are older than 70 years of age
RCA_framework_10.10.17.docx