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About 10,000 papers for “Root cause analysis”

Root Cause Analysis

Mark M. Stecker · Journal of Vascular and Interventional Radiology · 2007

Cited by 15

Root-Cause Analysis

Geetha Jayaram · Oxford University Press eBooks · 2015

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

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 Analysis

Luis Tueme, Nawal E. Ragheb-Mueller · 2023

Abstract Root cause analysis (RCA) is a tool intended to analyze the roots of a problem in a structured and meticulous manner so that the underlying cause, contributing factors, or system vulnerabilities of an incident are identified and addressed in an effort to prevent future adverse events. Sentinel events (those that can cause death or severe temporary or permanent harm) are the usual focus of an RCA. To enhance the likelihood of preventing future events, RCA focuses on systemic and procedural flaws, rather than on individual performance. An RCA begins with the formation of a team to investigate a specific sentinel event. The team will define all issues clearly and in chronological order, brainstorm all possible contributing factors, and analyze each factor. Ultimately, the goal is to develop and implement systemic changes that will prevent future harmful events.

Cited by 0

Root Cause Analysis

Matthew Barsalou · Productivity Press eBooks · 2014

Although there are many books on root cause analysis (RCA), most concentrate on team actions such as brainstorming and using quality tools to discuss the failure under investigation. These may be necessary steps during RCA, but authors often fail to mention the most important member of an RCA team the failed part.Root Cause Analysis: A Step-By-Step

Cited by 21

Root-cause analysis.

Parinaz Abiri (18880843), Il Seok Daniel Jeong (18880846), Amber Verdell (18880849) et al. · Figshare · 2024

<p>By identifying the primary reasons for low prescription rate of MATs for AUD, we were able to target a key hospital resource to resolve several of the major failure points.</p>

Cited by 0Open access

Root Cause Analysis

Louise Kelly, Chris Booth · Dictionary of Strategy: Strategic Management A-Z · 2004

Cited by 1

Root Cause Analysis

Joemart Contreras · Journal of Clinical Engineering · 2021

In the summer of 2020, a patient at a major Veteran Affairs medical center in the western United States experienced an unwitnessed fall in their telemetry patient ward. This incident resulted in the patient receiving a fracture in his/her C5 cervical spine area. This eventually led to his/her death the following day. After determining a Safety Assessment Code score of 3, the patient safety manager determined that an immediate root cause analysis (RCA) was required. After assembling an interdisciplinary team and providing training on the VA's RCA policies and processes, an initial timeline of the sequence of the events was created. After identifying the gaps, personnel were interviewed, and using triage questions, the full flow diagram of the incident was created. By understanding what had occurred, the team was able to find the root causes of key events within the timeline. Four root causes were determined. One was the lack of an immobilization protocol for patients who sustained injuries from a fall. The second was the misinterpretation of the restraint policy by the nursing staff. The third was failing to identify risk factors associated with a patient's Morse fall risk score. Finally, the last root cause was the improper patient bed configuration of using a mattress from a different vendor. All these root causes received action plans that seek to reduce future problems from occurring. Although I had limited time with the overall RCA project, I learned a lot about the VA process and how important and valuable a good RCA is in preventing issues from occurring again and ensuring patient safety is held to the highest priority for a hospital and healthcare system.

Cited by 0