You must investigate to determine WHY the human error occurred. Unfortunately, the discovery that a human has erred does little to aid the prevention process. Most of our mishaps involve at least one human error. Rule 3 - Each human error must have a preceding cause.To force clear cause and effect descriptions (and avoid inflammatory statements), we recommend against the use of any negative descriptor as a placeholder for a more accurate, clear description. We may shorten our findings by saying "maintenance manual was poorly written" when we really have a much more detailed explanation in our mind (e.g., "9 point font, and no illustrations"). Unfortunately, this human tendency works it way into the documentation process. Rule 2 - Negative descriptors (e.g., poorly, inadequate) are not used in causal statements.Īs humans, we try to make each job we have as easy as possible.The bottom line: the reader needs to understand your logic in linking your causes to the outcome. Even a statement like "resident was fatigued" is deficient without your description of how and why this led to a slip or mistake. Focus on showing the link from your root cause to the undesirable patient outcome you are investigating. When describing why an event has occurred, you should show the link between your root cause and the bad outcome, and each link should be clear to the RCA Team and others. ![]()
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