Strong vs Weak Responses l No effect at

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Strong vs. Weak Responses l No effect at all l RCA examples: Train/retrain n

Strong vs. Weak Responses l No effect at all l RCA examples: Train/retrain n Blame/Reprimand n

Strong vs. Weak Responses l Almost no effect l RCA Examples: Write a new

Strong vs. Weak Responses l Almost no effect l RCA Examples: Write a new procedure/policy n Add another step n Add just a little more technology n

Strong vs. Weak Responses l More Effective l RCA Example: n Double checks

Strong vs. Weak Responses l More Effective l RCA Example: n Double checks

Strong vs. Weak Responses l A Bit More Effective l RCA examples: Feedback from

Strong vs. Weak Responses l A Bit More Effective l RCA examples: Feedback from devices n Redundancy n

Strong vs. Weak Responses l More Effective l RCA examples: Increase staffing/decrease workload n

Strong vs. Weak Responses l More Effective l RCA examples: Increase staffing/decrease workload n Reduce distractions n

Strong vs. Weak Responses l More Effective l RCA examples: Checklist/cognitive aids/decision support n

Strong vs. Weak Responses l More Effective l RCA examples: Checklist/cognitive aids/decision support n Enhance communication n Hearback, readback, etc. n

Strong vs. Weak Responses l A Lot More Effective l RCA examples: Physical changes

Strong vs. Weak Responses l A Lot More Effective l RCA examples: Physical changes to environment n Simplification/removal unnecessary steps n Standardization n

Strong vs. Weak Responses l Most Effective l RCA Examples: Forcing functions n Constraints

Strong vs. Weak Responses l Most Effective l RCA Examples: Forcing functions n Constraints n

Weak Responses to an RCA Train/retrain l Blame/Reprimand l Write a new procedure/policy l

Weak Responses to an RCA Train/retrain l Blame/Reprimand l Write a new procedure/policy l Add another step l Add just a little more technology l Double checks l

Strong Responses to an RCA Forcing functions l Constraints l Physical changes to environment

Strong Responses to an RCA Forcing functions l Constraints l Physical changes to environment l Simplification/removal unnecessary steps l Standardization l

Intermediate Responses to an RCA Increase staffing/decrease workload l Reduce distractions l Checklist/cognitive aids/decision

Intermediate Responses to an RCA Increase staffing/decrease workload l Reduce distractions l Checklist/cognitive aids/decision support l Enhance communication l Hearback, readback, etc. l Feedback from devices l Redundancy l