Prompts Root Cause Analysis Findings Root cause Plan of Action the patients

Question15To what degree was the communication among participantsadequate for this situation? Prompts Root Cause Analysis Findings Root cause Plan of Action the patient’s condition, treatment and response to treatment. Describe staff utilization and adequacy of policy, procedure, protocol and guidelines specific to the patient care provided. in your response, as appropriate:The timing of communication of key informationMisunderstandings related to language/cultural barriers, abbreviations, terminology, etc. 16Was this the appropriate physical environment for the processes being carried out for this situation?Consider processes that proactively manage the patient care environment. This response may correlate to the response in question 6 on a more global scale.What evaluation tool or method is inplace to evaluate process needs andmitigate physical and patient care environmental risks? How are these process needs addressed organization-wide? Page 8

RCA Framework Revised 3/21/2013 # Analysis Question Prompts Root Cause Analysis Findings Root cause Plan of Action  evaluation of egress points  patient acuity level and setting of care managed across the continuum,  preparation of medication outside of pharmacy 17 What systems are in place to identify environmental risks? Identify environmental risk assessments.  Does the current environment meet codes, specifications, regulations?  Does staff know how to report environmental risks?  Was there an environmental risk involved in the event that was not previously identified? 18 What emergency and failure- mode responses have been planned and tested? Describe variances in expected process due to an actual emergency or failure mode response in connection to the event. Related to this event, what safety evaluations and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)? Emergency responses may include, but are not limited to:  Fire  External disaster  Mass casualty  Medical emergency Failure mode responses may include, but are not limited to: Page 9

RCA Framework Revised 3/21/2013 # Analysis Question Prompts Root Cause Analysis Findings Root cause Plan of Action  Computer down time  Diversion planning  Facility construction  Power loss  Utility issues