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Discussion Posts and Replies
, You are educating clinical managers in your healthcare facility on how to identify appropriate events for
conducting a Root Cause Analysis. Which event provides the best opportunity for an RCA? - correct
ans:a. A post-op patient removes his own IV causing a skin tear from the tape
b. A patient with no known allergies experiences an anaphylactic reaction to an antibiotic requiring
transfer to ICU.
c. The biopsy samples from a colonoscopy are never received by pathology after the procedure
d. There have been 3 occurrences of depressed respirations in the same department in the last 4
months related to sedation
The answer is C. The biopsy samples from a colonoscopy are never received by pathology after the
procedure - correct ans:
The instrument count is incorrect at the conclusion of a surgical procedure. The hospital policy does not
stipulate that the surgeon remain on the premises until an x-ray is obtained. The surgeon leaves the
hospital to catch a flight. The x-ray reveals a retained instrument. Another surgeon is contacted to
remove the retained instrument. What should leadership do next? - correct ans:a. Create a process map
of how instruments are managed during surgery looking for latent flaws
b. Revise the hospital policy to make it clear that surgeons must stay in the OR until instrument count
issues are resolved
c. Counsel the surgeon about customary clinical standards for a surgeon using appropriate
accountability system
d. Reeducate the OR nursing staff on keeping track of instruments on the sterile field
The answer is C. Counsel the surgeon about customary clinical standards for a surgeon using appropriate
accountability system - correct ans: