CPSI, Root Cause Analysis Workbook - Paediatric Chairs of Canada

CANADIAN ROOT CAUSE ANALYSIS FRAMEWORKUnited States Joint Commission International Center for Patient Safetyhttp://www.jcipatientsafety.org/Contentshttp://www.jcipatientsafety.org/show.asp?durki=9754&site=165&return=9368• Affirmation Statement• Framework for Conducting a Root Cause Analysis• Tool to Assist Organizations in the Completion of the Framework for Conducting a Root CauseAnalysis• Process Flow Chart – for event reporting and responses• Root Cause Analysis Matrix• Self-Report FormJoint Commission Resourceshttp://www.jcrinc.com/United States Veterans Affairs National Center for Patient Safetyhttp://www.patientsafety.govContents:• Root Cause Analysis (RCA)http://www.va.gov/ncps/rca.html• Triggering & Triage Questionshttp://www.va.gov/ncps/SafetyTopics/CogAids/triage/index.html• Five Rules of Causationhttp://www.va.gov/ncps/SafetyTopics/CogAids/Triage/index.html• Ensuring Correct Patient Surgeryhttp://www.patientsafety.gov/SafetyTopics.html#ECS• MRI Hazard Summaryhttp://www.patientsafety.gov/SafetyTopics/mrihazardsummary.html• Healthcare Failure Mode and Effects Analysis (HFMEATM)http://www.patientsafety.gov/SafetyTopics.html#HFMEA• Falls Prevention Toolkithttp://www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html• Patient Safety Curriculum Workshop: How to Teach Medical Residentshttp://www.patientsafety.gov/PSC/Workshop.htmlSoftware• Medical Risk Management Associates, LLChttp://www.rootcauseanalyst.com/• REASON Root Cause Analysishttp://www.rootcause.com/Welcome.html• Reliability Center, Inc.http://www.reliability.com/Training and Toolkits• National Health Services (NHS). National Patient Safety Agency. Maureen Baker. NPSA e-learningprogramme for Root Cause Analysis. United Kingdom, CAPITA Consulting, http://www.aafp.org/PreBuilt/research_baker.pdf.37