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Case Study A7 - Discussion - Answer (Question 7)

TraQ Program of the BC PBCO

Home Case Studies A-Level Case A7: Inter-facility Transportation of RBCs Case Study A7 - Discussion - Answer (Question 7)
Tuesday, 14 August 2018

Case Study A7 - Discussion - Answer (Question 7)

In a quality system how are  errors handled?

A quality system focuses on:

  • systems and processes rather than individual performance

  • reporting errors without fear of blame

  • root cause analysis to identify actual cause and contributing factors

  • culture of questioning and constant learning

In this case the system failed. Important contributory factors included

  • absence of formal and documented training and competency assessment programs

  • staff communication difficulties

Last modified on Tuesday, 18 October 2016 12:15