PATIENT SAFETY: IHI PS 201 ROOT CAUSE ANALYSES NEWEST
ACTUAL EXAM WITH VERIFIED QUESTIONS AND DEFINITIVE
ANSWERS
The five rules of causation include:
1) clearly show the cause and effect relationship.
2) use specific and accurate descriptors for what occurred.
3) human error must have a preceding cause.
4) violations of procedure are not a cause, but must have a
preceding cause.
5) failure to act is only causal when there is a pre-existing
duty to act.
An rca2 team is launching an investigation of a surgical error.
If they complete an effective review, which of the following is
an example of a root cause they might identify?
(a) the surgeon did not listen to the nurse.
(b) the patient was male.
(c) the hierarchy in the operating room had a negative effect
upon communication.
(d) all of the above
C
pg. 1
, Rca2 is meant to identify system failures that place patients at
risk. Poor communication due to hierarchy is an example of an
inherent problem in the system that could cause it to fail. If the
surgeon failed to listen to the nurse, it would be a symptom of
this larger problem.
Which of the following is a recommendation for effective
interviewing during rca2?
(a) avoid writing questions ahead of time to keep an open
mind.
(b) the entire rca2 team should be present at each interview to
hear first-hand accounts.
(c) set the right tone by expressing your own regret about
what happened.
(d) speculate why you personally believe the incident
occurred.
C
Rca2 interviews are often emotional and require sensitivity. To
set the right tone for the interview, especially with a patient or
family member, it is appropriate to express your regret that an
unfortunate outcome or near miss occurred. However, do not
speculate at this point what caused the incident. Each
interview should involve only one or two rca2 team members.
pg. 2
ACTUAL EXAM WITH VERIFIED QUESTIONS AND DEFINITIVE
ANSWERS
The five rules of causation include:
1) clearly show the cause and effect relationship.
2) use specific and accurate descriptors for what occurred.
3) human error must have a preceding cause.
4) violations of procedure are not a cause, but must have a
preceding cause.
5) failure to act is only causal when there is a pre-existing
duty to act.
An rca2 team is launching an investigation of a surgical error.
If they complete an effective review, which of the following is
an example of a root cause they might identify?
(a) the surgeon did not listen to the nurse.
(b) the patient was male.
(c) the hierarchy in the operating room had a negative effect
upon communication.
(d) all of the above
C
pg. 1
, Rca2 is meant to identify system failures that place patients at
risk. Poor communication due to hierarchy is an example of an
inherent problem in the system that could cause it to fail. If the
surgeon failed to listen to the nurse, it would be a symptom of
this larger problem.
Which of the following is a recommendation for effective
interviewing during rca2?
(a) avoid writing questions ahead of time to keep an open
mind.
(b) the entire rca2 team should be present at each interview to
hear first-hand accounts.
(c) set the right tone by expressing your own regret about
what happened.
(d) speculate why you personally believe the incident
occurred.
C
Rca2 interviews are often emotional and require sensitivity. To
set the right tone for the interview, especially with a patient or
family member, it is appropriate to express your regret that an
unfortunate outcome or near miss occurred. However, do not
speculate at this point what caused the incident. Each
interview should involve only one or two rca2 team members.
pg. 2
