Abstract This chapter briefly outlines the reasons for and means of conducting a root-cause analysis of an adverse event in an inpatient or outpatient setting. Examples, and links to websites that detail the steps involved, are provided. The chapter is not meant to be an exhaustive report, but rather encourages the reader to use a systems perspective in reviewing an event. This involves promotion of information gathering and constructive feedback and re-engineering of systems to prevent harm. Some approaches for this analysis include failure modes effects analysis, and a systems analysis. Important to this effort is a culture of safety in which care is subjected to constant scrutiny for areas of vulnerability.

Cited by 1

Root Cause Analysis

2001

Cited by 0

The Root Cause

Wong, Devon · cIRcle (University of British Columbia) · 2010

The Root Cause is an investigative documentary that explores local food security issues after learning some alarming statistics relating to urban poverty in the City of Richmond. The film reveals an overwhelming public unawareness, increasing institutional concern and a strong grassroots movement to address food insecurity within the community.

Cited by 0

Root Cause Analysis

Aarti Raghavan · 2015

Cited by 4

Root Cause — Clarity

Series on resource management · 2006

Cited by 0

Root Cause Analysis

Mark A. Latino, Robert J. Latino, Kenneth C. Latino · 2019

This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human reliability is critical to the success of a true RCA approach. This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being's ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates reliability to safety as well as human performance improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results. Features Outlines in detail every aspect of an effective RCA ‘system’ Displays appreciation for the role of understanding the physics of a failure as well as the human and system’s contribution Demonstrates the role of RCA in a comprehensive Asset Performance Management (APM) system Explores the correlation between Reliability Engineering and Safety Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA

Cited by 18

Root-Cause Regulation

Michael J. Piore, Andrew Schrank · Harvard University Press eBooks · 2018

Work is more deadly than war, and the U.S. has one of the highest rates of occupational fatality in the developed world. Why, after a century of reform, are U.S. workers growing less secure? Michael Piore and Andrew Schrank show how regulation can be a generative force for both workers and employers, rather than the job-killer of neoliberal theory.

Cited by 54

Search 250 million research papers

Root cause

Root Cause

Root Cause Analysis

Root Cause — Information

Root-Cause Clusters

Root-Cause Clusters

Root-Cause Clusters

Root Cause Analysis

Root-Cause Analysis

Root Cause Analysis

The Root Cause

Root Cause Analysis

Root Cause — Clarity

Root Cause Analysis

Root-Cause Regulation

Root Cause Analysis

Root Cause Analysis

Root cause analysis

Root Cause Analysis

Root cause analysis