Sample Trigger Questions for Performing a Root Cause Analysis of a Blood or Body Fluid Exposure

 

1. Issues related to patient assessment

• Was the patient agitated before the procedure?
• Was the patient cooperative before the procedure?
• Did the patient contribute in any way toward the event?

 

2. Issues related to staff training or staff competency

• Did the healthcare worker receive training on injury prevention technique for the procedure per­formed?
• Are there training or competency factors that contributed to this event?
• Approximately how many procedures of this type has the healthcare worker performed in the last month/week?

 

3. Issues related to the device

• Did the type of device used contribute in any way to this event?
• Was a “safety” device used?
• If not, is it likely that a safety device could have prevented this event?

 

4. Work environment

• Did the location, fullness or lack of a sharps container contribute to this event?
• Did the organization of the work environment (e.g., placement of supplies, position of patient) influence the risk of injury?
• Was there sufficient lighting?
• Was crowding a factor?
• Was there a sense of urgency to complete the procedure?

 

5. Was a lack of or misinterpretation of information contribute to this event?

• Did the healthcare worker misinterpret any information about the procedure that could have con­tributed to the event?

 

6. Communication

• Were there any communication barriers (e.g., language) that contributed to this event ?
• Was communication in any way a contributing factor in this event?

 

7. Appropriate policies/procedures

• Are there existing policies or procedures that describe how this event should be prevented?
• Were the appropriate policies or procedures followed?
• If they were not followed, why not?

 

8. Worker issues

• Did being right or left handed influence the risk?
• On the day of the exposure, how long had the worker been working before the exposure oc­curred?
• At the time of the exposure, could factors such as worker fatigue, hunger, illness, etc. have con­tributed?

 

9. Employer issues

• Did lack of supervision contribute to this event?

 

Source: CDC

Read more about sharps injury prevention:

 

– Sample Baseline Assessment Worksheet for Sharps Injury Prevention Program

 

– Sample Survey of Device Use for Sharps Injury Prevention Program

 

– Sharps Injuries Still High Despite Legislation and Improved Technology