Decision to do an RCA The RCA Process

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Decision to do an RCA The RCA Process An Overview VA National Center for

Decision to do an RCA The RCA Process An Overview VA National Center for Patient Safety REV. 02. 26. 2015 1

Decision to do an RCA Flow Chart Process Guide VA National Center for Patient

Decision to do an RCA Flow Chart Process Guide VA National Center for Patient Safety REV. 02. 26. 2015 2

Decision to do an RCA VA National Center for Patient Safety REV. 02. 26.

Decision to do an RCA VA National Center for Patient Safety REV. 02. 26. 2015 3

Decision to do an RCA Immediate Actions As Required VA National Center for Patient

Decision to do an RCA Immediate Actions As Required VA National Center for Patient Safety REV. 02. 26. 2015 4

Decision to do an RCA Charter/Appoint Team VA National Center for Patient Safety REV.

Decision to do an RCA Charter/Appoint Team VA National Center for Patient Safety REV. 02. 26. 2015 5

Decision to do an RCA Just in Time Training for Team VA National Center

Decision to do an RCA Just in Time Training for Team VA National Center for Patient Safety REV. 02. 26. 2015 6

Decision to do an RCA Establish Sequence of Events (First Draft) VA National Center

Decision to do an RCA Establish Sequence of Events (First Draft) VA National Center for Patient Safety REV. 02. 26. 2015 7

Decision to do an RCA Identify Information Gaps VA National Center for Patient Safety

Decision to do an RCA Identify Information Gaps VA National Center for Patient Safety REV. 02. 26. 2015 8

Decision to do an RCA Specify Information Required/Who is Responsible to Get It/ Timeline

Decision to do an RCA Specify Information Required/Who is Responsible to Get It/ Timeline for Acquiring VA National Center for Patient Safety REV. 02. 26. 2015 9

Decision to do an RCA Use Triage Questions and RC/Contributing Factor Interview Tools to

Decision to do an RCA Use Triage Questions and RC/Contributing Factor Interview Tools to Frame Questions VA National Center for Patient Safety REV. 02. 26. 2015 10

Decision to do an RCA Conduct Fact Finding Interviews, Chart Reviews, and Literature Reviews

Decision to do an RCA Conduct Fact Finding Interviews, Chart Reviews, and Literature Reviews VA National Center for Patient Safety REV. 02. 26. 2015 11

Decision to do an RCA Synthesize Information Acquired and Review Using ‘Triage Questions’ and

Decision to do an RCA Synthesize Information Acquired and Review Using ‘Triage Questions’ and Other Resources VA National Center for Patient Safety REV. 02. 26. 2015 12

Decision to do an RCA Information Needed Frame Questions As Needed Synthesize Fact Finding

Decision to do an RCA Information Needed Frame Questions As Needed Synthesize Fact Finding VA National Center for Patient Safety REV. 02. 26. 2015 13

Decision to do an RCA Final Version of Sequence of Events VA National Center

Decision to do an RCA Final Version of Sequence of Events VA National Center for Patient Safety REV. 02. 26. 2015 14

Decision to do an RCA Identify Root Cause/ Contributing Factors VA National Center for

Decision to do an RCA Identify Root Cause/ Contributing Factors VA National Center for Patient Safety REV. 02. 26. 2015 15

Decision to do an RCA Identify Corrective Actions That Were Instituted Due to a

Decision to do an RCA Identify Corrective Actions That Were Instituted Due to a Similar Event in the Past VA National Center for Patient Safety REV. 02. 26. 2015 16

Decision to do an RCA Develop Action Plan (First Draft) VA National Center for

Decision to do an RCA Develop Action Plan (First Draft) VA National Center for Patient Safety REV. 02. 26. 2015 17

Decision to do an RCA Provide Feedback to Reporter VA National Center for Patient

Decision to do an RCA Provide Feedback to Reporter VA National Center for Patient Safety REV. 02. 26. 2015 18

Decision to do an RCA Identify What was Learned and Who Needs to Know

Decision to do an RCA Identify What was Learned and Who Needs to Know VA National Center for Patient Safety REV. 02. 26. 2015 19

Decision to do an RCA Create Action Plan for Director Concur/ Non-Concur VA National

Decision to do an RCA Create Action Plan for Director Concur/ Non-Concur VA National Center for Patient Safety REV. 02. 26. 2015 20

Decision to do an RCA Iterate and Record as Necessary VA National Center for

Decision to do an RCA Iterate and Record as Necessary VA National Center for Patient Safety REV. 02. 26. 2015 21

Decision to do an RCA Determine Approximate Cost of RCA VA National Center for

Decision to do an RCA Determine Approximate Cost of RCA VA National Center for Patient Safety REV. 02. 26. 2015 22

Decision to do an RCA Final RCA and Action Plan Sign-Off VA National Center

Decision to do an RCA Final RCA and Action Plan Sign-Off VA National Center for Patient Safety REV. 02. 26. 2015 23

Decision to do an RCA Advisor Conducts Follow-Up VA National Center for Patient Safety

Decision to do an RCA Advisor Conducts Follow-Up VA National Center for Patient Safety REV. 02. 26. 2015 24

Decision to do an RCA Thank You! VA National Center for Patient Safety REV.

Decision to do an RCA Thank You! VA National Center for Patient Safety REV. 02. 26. 2015 25

Quo vadis RCA RCA asigurare cu caracter socialQuo vadis RCA RCA asigurare cu caracter social
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RCA PANEL DISCUSSION KEYNOTE ADDRESS THE RCA YESTERDAYRCA PANEL DISCUSSION KEYNOTE ADDRESS THE RCA YESTERDAY
ROOT CAUSE ANALYSIS RCA La RCA unanalisi dettagliataROOT CAUSE ANALYSIS RCA La RCA unanalisi dettagliata
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Rational Decision Making SSEF 2 Decision Making DecisionRational Decision Making SSEF 2 Decision Making Decision
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Decision Trees and Decision Tables Decision Trees andDecision Trees and Decision Tables Decision Trees and
Decision Making Contents Basics Decision Decision Types DecisionsDecision Making Contents Basics Decision Decision Types Decisions
Decision Analysis Steps in Decision making Decision analysisDecision Analysis Steps in Decision making Decision analysis
Decision Making DECISION MAKING A decision is aDecision Making DECISION MAKING A decision is a
Decision Trees and Tables Decision Trees and DecisionDecision Trees and Tables Decision Trees and Decision
Decision Making Spring 2007 Decision Making 1 DecisionDecision Making Spring 2007 Decision Making 1 Decision
CHAPTER 8 DECISION MAKING Organizational Decision Types DecisionCHAPTER 8 DECISION MAKING Organizational Decision Types Decision
Decision trees Decision trees A decision tree isDecision trees Decision trees A decision tree is
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Decision Matrix Develop a Decision Matrix A decisionDecision Matrix Develop a Decision Matrix A decision
Decision Trees Decision Trees Supervised Learning learn decisionDecision Trees Decision Trees Supervised Learning learn decision
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