CHSP Incident Investigation and Analysis 3 — Questions and Answers
Question 1: What is the primary goal of incident investigation in healthcare?
- To determine which employee to discipline
- To identify system factors that contributed to the event and develop actions to prevent recurrence (Correct answer)
- To prepare legal defense documentation
- To calculate the financial cost
Correct answer: To identify system factors that contributed to the event and develop actions to prevent recurrence
The primary goal is to identify underlying system factors so corrective actions can prevent similar events.
A systems-focused investigation examines task/environment, individual, team, organizational, and institutional factors to develop corrective actions addressing root causes.
Question 2: What is the 5 Whys technique used for in incident analysis?
- To ask five different people what happened
- To iteratively ask why to drill down from surface cause to root cause (Correct answer)
- To investigate five incidents at a time
- To complete investigation within five days
Correct answer: To iteratively ask why to drill down from surface cause to root cause
The 5 Whys involves repeatedly asking why to peel back layers of causation until the root cause is identified.
Originally developed by Sakichi Toyoda for Toyota. The process continues (not necessarily exactly five times) until reaching a root cause that if addressed would prevent recurrence.
Question 3: What is the purpose of a fishbone (Ishikawa) diagram in incident analysis?
- To plan the cafeteria menu
- To visually organize potential causes into categories to identify contributing factors systematically (Correct answer)
- To draw the organizational hierarchy
- To map facility layout
Correct answer: To visually organize potential causes into categories to identify contributing factors systematically
A fishbone diagram visually organizes potential causes into categories like people, process, equipment, and environment.
Common healthcare categories include People, Process, Equipment, Environment, Materials, and Management. The diagram prevents tunnel vision by ensuring all cause categories are considered.
Question 4: What distinguishes a near miss from an adverse event in healthcare incident reporting?
- There is no meaningful difference
- A near miss could have caused harm but was caught, while an adverse event actually resulted in harm (Correct answer)
- Near misses only involve medication
- Near misses only count if a supervisor witnesses them
Correct answer: A near miss could have caused harm but was caught, while an adverse event actually resulted in harm
A near miss had potential to cause harm but was intercepted, while an adverse event actually resulted in patient harm.
Near misses occur 3-300 times more often than adverse events, provide learning opportunities without harm, and reveal the same system weaknesses.
Question 5: What is a common timeline requirement for completing a root cause analysis after a sentinel event?
- Within 24 hours
- Within 45 days of the event or becoming aware of it (Correct answer)
- Within one year
- No timeline requirement exists
Correct answer: Within 45 days of the event or becoming aware of it
The Joint Commission expects a thorough RCA and action plan within 45 calendar days.
The 45 days include assembling the team, data gathering, interviews, root cause identification, developing corrective actions, and documentation. Immediate protective actions should be taken during investigation.
Question 6: Why is it important to interview witnesses as soon as possible after an incident?
- To pressure witnesses
- Because memory accuracy degrades over time and details are best recalled soon after (Correct answer)
- To prevent attorney consultation
- Written reports are always sufficient
Correct answer: Because memory accuracy degrades over time and details are best recalled soon after
Witness interviews should be conducted soon after the event because memory accuracy decreases rapidly and details may become confused.
Best practices include interviewing within hours to days, interviewing separately, using open-ended questions, allowing the witness to tell their story first, and documenting accurately.
CHSP Incident Investigation and Analysis 3
What is the primary goal of incident investigation in healthcare?