A root cause analysis (RCA) is required when a serious incident occurs, such as a "never event" or a sentinel event, which includes a procedure performed on the wrong knee. This type of incident is considered a significant error that could cause severe harm to the patient and is a clear indicator of a breakdown in the system that requires thorough investigation through an RCA to prevent recurrence.
* Incorrect critical care patient transported to radiology (A): While concerning, this may not reach the threshold for a required RCA unless it led to significant harm.
* Admitting a visitor who fell on hospital grounds (B): This incident may require investigation but typically would not trigger an RCA unless the fall resulted in severe injury.
* Wrong prescription given to a discharged patient with diabetes (C): This is serious but does not usually require an RCA unless it led to severe consequences.
References
* NAHQ Body of Knowledge: Incident Reporting and Root Cause Analysis
* NAHQ CPHQ Exam Preparation Materials: Conducting Root Cause Analysis
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