Adapted from ARHQ PSNet
Li Ka Shing Knowledge Institute - St. Michael's Hospital by JasonParis is licensed under CC BY 2.0.
A laboratory aide was cleaning one of the gross dissection rooms where the residents work. This aide was a relatively new employee who had transferred to the department just a few days prior to the event. When she was cleaning the sink in the dissection room, she accidentally ran her thumb along the length of a dissecting knife - an injury that required 10 to 15 stitches. Since there had been other less serious accidents in this room and several previous attempts to address the safety issues had not been effective, the department completed a root cause analysis.
Adapted from US National Library of Medicine National Institutes of Health
Drag and rearrange the panels on the right hand side in order to match the panels on the left hand side. Start by identifying the problem or "root cause" on the right hand side and drag it to the top position. From there, reorder each of the 5 causes.
When you have ordered the problem and causes correctly, the activity will automatically proceed to the next slide panel.
To skip this exercise, place the cursor in the red bar above, hold down left click on your mouse or tablet, and press "5" to skip to the next panel.
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD) was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, she had recently completed a course of tetracycline for an asymptomatic infection with Actinomyces israelii discovered on Pap smear. After the patient was in the operating room and prepared for the procedure, the team discovered that the equipment typically used for hysteroscopy was unavailable - the case had been listed only as a "D&C" on the operating room (OR) schedule, so the hysteroscopy set had not yet been sterilized after use earlier in the day. To avoid cancelling the procedure, the team borrowed sterile parts from various other hysteroscopy sets.
During insufflation of the uterus, the patient suffered cardiac arrest presumably related to air embolus. The patient was successfully resuscitated. After an 8-day stay in the intensive care unit, the patient was discharged home with no permanent sequelae.
Adapted from US D H&HS Agency for Healthcare Research and Quality
Adapted from NHS National Patient Safety Agency
Move each detail from the adverse event into the factor category under which it falls.Remember to place the problem, or issue, at the head of the fish.
The event details are contained within the black-bordered boxes to the right and left. Drag and drop each of them on top of the appropriate factor category (these boxes contain the blue text). If you have matched the event with the factor correctly, the event will move underneath the category. If it has not been matched correctly, the box will return to its starting point. You will also need to drag the problem into the head of the fish. When everything has been placed correctly, you will be directed to continue.
To skip this exercise, place the cursor in the red bar above, hold down left click on your mouse or tablet, and press "9" to skip to the next panel.
Adapted from NHS National Patient Safety Agency
Adapted from NHS National Patient Safety Agency
Adapted from NHS National Patient Safety Agency
2018_0316_OSUCascades_Hospitality_JennaBrasada-38(2) by Oregon State University is licensed under CC BY-SA 2.0.