The page below is a sample from the LabCE course Medical Error Prevention: Patient Safety. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

Learn more about Medical Error Prevention: Patient Safety (online CE course) »
How to Subscribe
MLS & MLT Comprehensive CE Package
Includes 94 CE courses, most popular
$95 Add to cart
Pick Your Courses
Up to 8 CE hours
$50 Add to cart
Florida HIV Safety, Medical Errors & Laws and Rules$40 Add to cart
Histology CE Package$65 Add to cart
Phlebotomy CE Package$45 Add to cart
Individual course$20 Add to cart

RCA Example

One of the tools that can be used when performing an RCA is the cause-and-effect diagram, which is often referred to as a "fishbone diagram" because of its appearance.

Cause-and-Effect (Fishbone) Diagram Example

This type of diagram graphically helps identify and organize known or possible causes for a specific problem or area of concern.

In this theoretical example, the identified problem is a "near miss." Two units of RBCs were taken to the Dialysis unit for tranfusion of two different patients. The first unit was hung by one clinical person and started just as another clinical person noticed that the unit that he/she picked up for transfusing another patient had the wrong identifying information. The blood was stopped immediately on the first patient.

Some of the benefitsof constructing a "fishbone diagram" are that it

  • Helps determine root causes using a structured approach.
  • Encourages group participation and utilizes group knowledge.
  • Indicates possible variations in a process.
  • Indicates areas where more data should possibly be collected.