Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event (Page 3 of 3) in pdf

Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event Page 3

Sample Trigger Questions for Performing a Root Cause Analysis

of a Blood or Body Fluid Exposure

1. Issues related to patient assessment

5. Was a lack of or misinterpretation of

information contribute to this event?

Was the patient agitated before the

procedure?

Did the healthcare worker misinterpret

any information about the procedure

Was the patient cooperative before

the procedure?

that could have contributed to the

Did the patient contribute in any way

event?

toward the event?

6. Communication

2. Issues related to staff training or staff

Were there any communication

competency

barriers that contributed to this event

Did the healthcare worker receive

(e.g., language)

training on injury prevention technique

Was communication in any way a

for the procedure performed?

contributing factor in this event?

Are there training or competency

factors that contributed to this event?

7. Appropriate policies/procedures

Approximately how many procedures

Are there existing policies or

of this type has the healthcare worker

procedures that describe how this

performed in the last month/week?

event should be prevented?

Were the appropriate policies or

3. Issues related to the device

procedures followed?

Did the type of device used contribute

If they were not followed, why not?

in any way to this event?

Was a “safety” device used?

8. Worker issues

If not, is it likely that a safety device

Did being right or left handed

could have prevented this event?

influence the risk?

On the day of the exposure, how long

4. Work environment

had the worker been working before

Did the location, fullness or lack of a

the exposure occurred?

sharps container contribute to this

At the time of the exposure, could

event?

factors such as worker fatigue,

Did the organization of the work

hunger, illness, etc. have contributed?

environment (e.g., placement of

supplies, position of patient) influence

9. Employer issues

the risk of injury?

Did lack of supervision contribute to

Was there sufficient lighting?

this event?

Was crowding a factor?

Was there a sense of urgency to

complete the procedure?

A-9 Sample Form for Performing a Simple Root Cause Analysis

Page 2 of 2

Sharps Injury Prevention Workbook:

Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event Page 3

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