Back to the Future Using Root Cause Analysis as a Proactive Risk Management Tool

2014 ◽  
Author(s):  
Phillip Nidd ◽  
Terence Thorn ◽  
Monica K. Porter
Keyword(s):  
Asset Management ◽  
Human Error ◽  
Root Cause Analysis ◽  
Management Tool ◽  
Management Tools ◽  
Cause Analysis ◽  
Root Cause ◽  
Management Standards ◽  
Underlying Causes ◽  
Definition Of

Root Cause Analysis (RCA) can be an effective proactive methodology to forecast or predict probable events even before they occur. It’s use has been embraced by regulators and can be found in the most advanced management tools such as the recently published ISO 55000 series of international management standards for asset management. An RCA identifies both the obvious and the underlying causes of an event so that specific solutions can be implemented. A complete RCA consists of a clear definition of the issue, a thorough analysis supported with evidence and a specific action plant for implementing solutions. In this respect, what may have appeared as a material failure or “human error,” can often be shown to be the result of an inadequate infrastructure management systems or the failure of management processes. Generally thought of as a reactive method of identifying the causes of past incidents, this paper will describe the elements of an RCA and how it can be a powerful tool to identify systems or behaviors that when modified or corrected, will prevent recurrence of similar outcomes.

Human Error Root Cause Analysis

1996 ◽  
Vol 40 (24) ◽  
pp. 1272-1272
Author(s):  
Michael T. Collopy ◽  
Robert M. Waters
Keyword(s):  
Human Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Facebook as Marketing Tools for Organizations

2021 ◽  
pp. 117-131
Author(s):  
Siti Farzana Izzati Jaman ◽  
Muhammad Anshari
Keyword(s):  
Knowledge Management ◽  
Root Cause Analysis ◽  
Future Research ◽  
Management Tools ◽  
Cause Analysis ◽  
Root Cause ◽  
Knowledge Management Tools ◽  
Facebook Marketing

Facebook has become widely known around the globe. This chapter applies marketing techniques to Facebook. The concern of using Facebook for both users and marketers is also elaborated in this study. Scenarios will help marketers to comprehend how knowledge management tools like plan-do-check-act (PDCA) and root cause analysis (RCA) are used in Facebook marketing. Other than the concern risk, the chapter presents the importance of using Facebook as well as the implication of these technique for future research.

Facebook as Marketing Tools for Organizations

2019 ◽  
pp. 92-105 ◽  
Author(s):  
Siti Farzana Izzati Jaman ◽  
Muhammad Anshari
Keyword(s):  
Knowledge Management ◽  
Root Cause Analysis ◽  
Future Research ◽  
Management Tools ◽  
Cause Analysis ◽  
Root Cause ◽  
Knowledge Management Tools ◽  
Facebook Marketing

Facebook has become widely known around the globe. This chapter applies marketing techniques to Facebook. The concern of using Facebook for both users and marketers is also elaborated in this study. Scenarios will help marketers to comprehend how knowledge management tools like plan-do-check-act (PDCA) and root cause analysis (RCA) are used in Facebook marketing. Other than the concern risk, the chapter presents the importance of using Facebook as well as the implication of these technique for future research.

The Role of Human Error in Root Cause Analysis: Understanding Human Behavior

2019 ◽  
pp. 221-252
Author(s):  
Mark A. Latino ◽  
Robert J. Latino ◽  
Kenneth C. Latino
Keyword(s):  
Human Behavior ◽  
Human Error ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Multiple Systemic Contributors versus Root Cause

2016 ◽  
Vol 60 (1) ◽  
pp. 264-264 ◽  
Author(s):  
Katherine E. Walker ◽  
David D. Woods ◽  
Michael F. Rayo
Keyword(s):  
Adverse Events ◽  
Human Error ◽  
Space Station ◽  
Root Cause Analysis ◽  
Near Miss ◽  
Specific Sequence ◽  
Cause Analysis ◽  
Extravehicular Activity ◽  
Root Cause ◽  
Sequence Of Events

In 2013 NASA nearly drowned an astronaut during an Extravehicular Activity (EVA 23) on the International Space Station due to spacesuit water leakage. Indicators of trouble on the preceding EVA (22) were discounted. NASA carried out an investigation of the near miss event that is a sample of how root cause analysis is carried out in actual organizations (National Aeronautics and Space Administration, 2013). This paper contrasts the root cause analysis with a new analysis the authors carried out that captures how multiple systemic contributors combined to create the conditions that led up to the near miss. The new analysis illustrates the original finding from the late 1980s that accidents arise from multiple factors each necessary but only jointly sufficient (Reason, 1990; Woods, 1990; Cook, 2000; Woods, Dekker, Cook, Johannesen, & Sarter, 2010). Many of these contributors are system factors that have been present (latent) in the organization for some time prior to the specific sequence of events. In other words, the accidents arose from organizational or systemic factors (Reason, 1997). In contrast, the traditional root cause analysis focuses on the human roles closest to the adverse event and only raises systemic issues in terms of vague generalities that are difficult to address in systemic improvements (Dekker, 2014; Woods et al., 2010). The paper provides this contrast for two purposes. The first goal of this paper is to provide a concrete technique and diagram for identifying systemic contributors to adverse events (Systemic Contributors Analysis and Diagram or SCAD). The second goal is to highlight how the current practice of root cause analysis is unable to come to grips with systemic issues, misses the interactions between contributors, and misses emergent system properties. Using this systemic technique reveals that adverse events are very often due to production pressure at the blunt end, not human error at the sharp end of systems.

scholarly journals How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

2020 ◽  
Vol 29 (6) ◽  
pp. 524-531
Author(s):  
Jimmy Martin-Delgado ◽  
Alba Martínez-García ◽  
Jesús María Aranaz ◽  
José L. Valencia-Martín ◽  
José Joaquín Mira
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Human Error ◽  
Root Cause Analysis ◽  
Care Process ◽  
Cause Analysis ◽  
Root Cause ◽  
Communication Problems ◽  
Practical Usefulness ◽  
Common Causes

<b><i>Objectives:</i></b> The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). <b><i>Methods:</i></b> A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. <b><i>Results:</i></b> Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; <i>n</i> = 18), and the type of incident most analysed was AAEs, in 71% (<i>n</i> = 15) of the cases; 47% (<i>n</i> = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. <b><i>Conclusions:</i></b> RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

Improving patient wait time by implementing visual management tools in an outpatient oncology infusion unit.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 200-200
Author(s):  
Kit Yu Lu ◽  
Candace Fuerst ◽  
Irina Veytsman
Keyword(s):  
Drug Delivery ◽  
Wait Time ◽  
Root Cause Analysis ◽  
High Impact ◽  
Staff Satisfaction ◽  
Blood Draw ◽  
Management Tools ◽  
Cause Analysis ◽  
Root Cause ◽  
Patient Wait Time

200 Background: The number of cancer diagnosis and oncology visits have increased by 30% over the past decade nationwide. Similarly, our institution also experienced more than 30% growth this past year due to increased number of physicians and patients. However, the amount of resources including staffing, infusion chairs, and hour of operation remained the same. This has caused significant delays for patients and decreased patient/staff satisfaction. Methods: Visual Management tools can be used to communicate information by using visual diagrams instead of text. Various instruments were used to visually assess patient flow during their chemotherapy admission in the infusion unit. The workflow process was organized into a Value Stream Map. Root cause analysis was performed for high problematic areas. Results: Average patient wait time were as follows: patient registration to infusion chair (20min; range 5-45min), chair to nurse assessment (15min; range 0-30min), blood draw to “ok for treatment” (60min; range15-90min), “ok to treatment” to drug delivery (20min; range 15-30min). Through visual stream mapping, we identified the complexity of work flow and areas of highest impact for patient wait time (ex. blood draw/laboratory process, drug delivery). We used root-cause analysis to identify deficiencies and limitation in the process. Pick chart was created to assess and stratify useful ideas and current resources. We achieved several low effort/high impact interventions (i.e. designated parking space for drug delivery, supplying tools in nursing stations) and some high effort/high impact interventions (i.e. extending office hours and making changes to our computer order systems). These strategies has improved efficiency and decreased wait time by more than 50%, and also improved patient and staff satisfaction. Conclusions: Incorporation of Visualization Management tools helped engaged our high stake holders in the improvement processes. These tools helped facilitate a deeper understanding of department workflow, identify issues in the process, standardize the process and improve efficiency.

scholarly journals Human Factors in Incident Investigation

1989 ◽  
Vol 33 (15) ◽  
pp. 1024-1028 ◽  
Author(s):  
Mark E. Armstrong
Keyword(s):  
South Carolina ◽  
Human Factors ◽  
Human Error ◽  
Reporting System ◽  
Root Cause Analysis ◽  
Savannah River Site ◽  
Savannah River ◽  
Cause Analysis ◽  
Root Cause ◽  
River Site

The Savannah River Site (SRS), located in South Carolina, is a key Department of Energy production and research facility for nuclear materials. Incident investigations performed at the Savannah River Site showed the cause of approximately 75% of all operating incidents in non-reactor facilities to be human error. The technical incident reporting system in place required the investigator to list the cause of an incident in broad terms (i.e., Personnel Error, Equipment Error) and to categorize it according to subclassifications (i.e., Operator Error, Supervisor Error, Mechanic Error). The reporting system, using these classifications, tended to emphasize “what happened” during an incident and “who was involved”, instead of getting to the details of “why” an incident occurred. The high rate of human error as the cause of incidents indicated that further analysis was in order. Human factors personnel in the Facility Safety Evaluation Section (FSES - an oversight organization with emphasis on non-reactor facilities) wanted to determine the causes of human error in a way that would identify more precisely why the errors occurred. To satisfy these needs, FSES is implementing a root cause analysis program for SRS. Root cause analysis consists of two parts; the first being Events and Causal Factor (E&CF) Charting; and the second, Root Cause Coding using a Root Cause Tree. The objectives were to provide a systematic method for identifying the root causes of a given incident in order to make detailed recommendations for preventing its recurrence, and to provide a database of incident root causes for identifying problem areas across incidents. Root cause analysis would guide the incident investigator to state “why” an incident occurred using detailed cause codes (e.g., Incomplete Training, Labels Less Than Adequate). Root cause trending would enable FSES to track the causes of human error, recommend solutions, and track corrective actions. FSES developed a one day workshop to train several hundred incident investigators at SRS to perform investigations using the root cause analysis method. This presentation will discuss the development and implementation of the root cause analysis system at SRS by FSES human factors professionals.

Sign in / Sign up

Export Citation Format

Share Document