Briefly describe the incidence including the patient outcome. For example, a wrong side surgery may be considered an incident
Describe the direct cause of this incident. A direct cause is an event or a person who physically affects the incident. Usually the direct cause occurs shortly before the incident. For example, fatigued nurse might be considered a contributing direct cause for wrong side surgery.
What could be the root cause of this incident? A root cause affects the incidence through the direct cause listed above. For example, understaffing might be considered a root cause for wrong side surgery because it leads to fatigued nurse.
Would you say that the relationship between the root cause and the direct cause is stronger than the relationship between the root cause and the incident? For the example we have been following this is to say that the relationship between understaffing and finding a fatigued nurse is stronger than the relationship between understaffing and finding an incident of wrong side surgery. Yes No Same strengthNot sure Do not understand the question
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Which relationship is stronger?
Root cause
Direct cause
Sentinel event
Root cause & direct cause
Root cause & sentinel event
Same