National Center for Patient Safety

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Patient Safety Interventions (Actions)
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2003
1999 - 2002
N1692
N2602
Types of Actions from RCAs
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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NCPS RCA/HFMEA Action Hierarchy
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ACTIONS

• Must specifically address the root
  cause/contributing factor
• Need to be specific, concrete, and clear
  understood by a cold reader
• Reality checked (with the process owners)
• Tested or simulated prior to full system-wide
  implementation

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To Summarize

• Work towards identifying strong or intermediation
  actions
• Develop outcome measures that are quantifiable
  and that measure the effectiveness of the action

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Semper Gumby
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Okay folks its a wrap