What is Root Cause Analysis (RCA)?

Swiss cheese model of accident causation

It is the investigational process of determining underlying issues or root causes that contribute to incidents with a significant undesirable or adverse outcome – a way of doing a thorough study that involves:

  • Carefully detailing and analyzing the sequence of events/condition with input from all involved parties.
  • Determining deviations from standards within the processes involved.
  • Identifying contributory and potential contributory factors to the event.
  • Identifying incidental findings – elements that are discovered that need improvement but that did not contribute to the critical event under review.
  • Literature review to establish evidence based practices.
  • And a resulting report that gives the Findings and Recommendations of the RCA group in relation to the investigation undertaken.

The purpose of the RCA is to review our systems and processes in order to prevent a similar incident from re– occurring after we have determined the root cause of the incident

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What is a Sentinel Event?

  1. A sentinel event is an unanticipated occurrence that may involve
    1. Death or major permanent loss of function unrelated to the patients’ illness or condition
    2. May occur due to wrong-site, wrong procedure, wrong-patient surgery and
    3. Signals a need for immediate investigation and response
  2. Sentinel events may also be serious breaches in standards, processes, procedures, policies or care environment that causes harm, loss, or risk thereof.

Notification of sentinel events is outlined in the Risk Management Program. A suspected sentinel event is brought to the immediate attention of the QI Coordinator and to the Chief of the Department, who decide if a sentinel event has occurred. If it is determined that the event is a sentinel event, a specialized team is assigned to perform a Root Cause Analysis (RCA) and report findings to Medical Management and the Quality Improvement Counsel Committee which implements the recommendations of the RCA to prevent reoccurrence.

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Hospital Quality Improvement and Patient Safety

Hospital Quality Improvement and Patient SafetyQPS processes provide the framework for the organization and its leaders to achieve a commitment to provide quality patient care in a safe, well-managed environment and reduce risk to patients, staff and visitors.

Do you know what model preferred to be used for Quality Improvement?

Answer: PDCA improvement model. This requires the chosen process to go through the Plan-Do- Check-Act cycle in order to bring about an improvement.

How are clinicians involved in Quality Improvement?


  1. All medical staff is involved in quality improvement through various activities in the organization.
  2. The quality improvement analysts assist the medical staff by using generic and service specific screening indicators to medical record documentation and patient care.
  3. This initial screening process generates referrals to clinicians for their peer review of any identified variances.
  4. Each division monitors important aspects of care, analyzes the data and report’s findings on a quarterly basis to the QI Office where they are aggregated and shared with Medical Management.
  5. Members of key committees also participate in QI activities by their ongoing analysis of data provided to the committee for action.
  6. The recent introduction of our Occurrence Reporting system gives staff easy access to identify issues of quality, safety, and potential risk that may require attention and intervention.

QI is every

Hospital Quality Improvement and Patient Safety

one’s business.

How has your department improved care or services?


  • Every division has selected topics or issues for monitoring. Be sure you are familiar with the monitors for your division, and are able to articulate the results of data collection and actions taken to improve.
  • If you are not familiar with your division QI information, ask for it to be discussed at your staff meetings.
  • You are also responsible for knowing what QI activities are monitored.

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Does a single atom cast a shadow?

Does a single atom cast a shadow

Does a single atom cast a shadow

Yes, single atoms do cast shadows! This has been understood for about 100 years but was only demonstrated experimentally recently, in this paper from 2012.

On the scale of things smaller than the wavelength of light, the shadow in the far field will never be smaller than the diffraction limit. Instead of a sharp outline that you see with macroscopic objects, the diffraction pattern formed by the shadow is a smooth function determined by the optics of the microscope.

Everything is partially transparent at this small scale as well, so the intensity of the shadow is determined by how much light the object can absorb. For individual atoms, the absorption is only significant at very narrow peaks in wavelength. So you need to be sure to tune your light source right at one of these peaks to get a decent shadow.

In the paper above, the authors trapped a single, laser-cooled ytterbium ion and used a light source tuned to a peak around 369.5 nm. That means they were imaging in UV, but in principle this approach could work with visible light as well. The final image showed about a 3% decrease in intensity at the center of the shadow. The wavelength of light used to illuminate the atom had to be precise to about one part per billion or the shadow disappeared.

Does a single atom cast a shadow? from askscience

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Abdominal Adhesions

What is the abdominal cavity?

The abdominal cavity is the internal area of the body between the chest and hips that contains the lower part of the esophagus, stomach, small intestine, and large intestine. The esophagus carries food and liquids from the mouth to the stomach, which slowly pumps them into the small and large intestines. Abdominal adhesions can kink, twist, or pull the small and large intestines out of place, causing an intestinal obstruction. Intestinal obstruction, also called a bowel obstruction, results in the partial or complete blockage of movement of food or stool through the intestines.

What causes abdominal adhesions? Abdominal surgery is the most frequent cause of abdominal adhesions. Surgery-related causes include cuts involving internal organs handling of internal organs drying out of internal organs and tissues contact of internal tissues with foreign materials, such as gauze, surgical gloves, and stitches blood or blood clots that were not rinsed away during surgery Abdominal adhesions can also result from inflammation not related to surgery, including appendix rupture radiation t

Source: Abdominal Adhesions | NIDDK

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Can ketoprofen and Celecoxib be used together?

Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of NSAID (COX-2 Inhibitor).

The prescribing information for both celecoxib and etoricoxib recommends avoiding concurrent use with any other NSAID due to an increased risk for adverse reactions,

So.. Concurrent use of another NSAID together with a COX-2 inhibitor is not recommended and should be avoided.

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Pharmacist error dispensing VENTOLIN

Medication error for VENTOLIN

The error happened as the pharmacy staff is using handwriting, and this might cause error and confusion for the patient. The pharmacist instead of telling the patient to use the dose of 1MG, she told him to use the dose of 1ML, which is five times more.

As a result of this matter, an OVR was initiated by the pediatrician and RCA was started.

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