Strong vs. Weak Responses

No effect at all

RCA examples: Train/retrain Blame/Reprimand

Strong vs. Weak Responses

Almost no effect

RCA Examples: Write a new

procedure/policy Add another step Add just a little more

technology

Strong vs. Weak Responses

More Effective

RCA Example: Double checks

Strong vs. Weak Responses

A Bit More Effective

RCA examples: Feedback from

devices Redundancy

Strong vs. Weak Responses

More Effective

RCA examples: Increase

staffing/decrease workload

Reduce distractions

Strong vs. Weak Responses

More Effective

RCA examples: Checklist/cognitive

aids/decision support Enhance communication Hearback, readback, etc.

Strong vs. Weak Responses

A Lot More Effective

RCA examples: Physical changes to

environment Simplification/removal

unnecessary steps Standardization

Strong vs. Weak Responses

Most Effective

RCA Examples: Forcing functions Constraints

Weak Responses to an RCA

Train/retrain Blame/Reprimand Write a new procedure/policy Add another step Add just a little more technology Double checks

Strong Responses to an RCA

Forcing functions Constraints Physical changes to environment Simplification/removal unnecessary

steps Standardization

Intermediate Responsesto an RCA

Increase staffing/decrease workload Reduce distractions Checklist/cognitive aids/decision support Enhance communication Hearback, readback, etc. Feedback from devices Redundancy