Root-Cause Analysis RCA

This method has been used for many years in the industrial sector to investigate industrial incidents and was originally developed by the U.S. Department of Energy [13,14]. RCA may be described as a systematic investigation approach that uses information collected during an assessment of an accident to determine the underlying factors for the deficiencies or shortcomings that led to the occurrence of the accident [15]. 

Ten general steps to perform RCA in the area of health care are as follows [1,16]  

Step 2 Inform all staff personnel whenever a sentinel event is reported. 

Step 4 Prepare for and conduct the first team meeting. 

Step 6 Identify and separate each event sequence that may have been a contributory factor in the sentinel event occurrence. 

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Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. However it is recognized that complete prevention of recurrence by a single intervention is not always possible. Thus RCA is often considered to be an iterative process and is frequently viewed as a tool of continuous improvement. 

An 800 person forum comprised of Root Cause Analysis (RCA) practitioners from all over the world tried to define Root Cause Analysis. They could not agree on an answer... It means different things to different industries—even different things within the same industries. It is even difficult to find consistency within the same companies, or even sites within a company. 

There is no formal process for continuous improvement or formal Root Cause Analysis (RCA). 

A method used to illustrate and pinpoint the likely causes of a concern. It is sometimes referred to as a Root Cause Analysis. It typically uses an Ishikawa (wish bone) or tree diagram (see Figure C.2), where the main concern is depicted at the head of the fish spine and the most likely causes are shown as the attached bones. When identified the root cause can be modified to eliminate or reduce the concern. See also Root Cause Analysis (RCA). 

Describe root cause analysis (RCA) along with its advantages and disadvantages. 

Chapter 3 presents introductory aspects of safety and human factors. Chapter 4 is devoted to methods considered useful to perform patient safety analysis. These methods include failure modes and effect analysis (FMEA), fault tree analysis (FTA), root cause analysis (RCA), hazard and operability analysis (HAZOP), six sigma methodology, preliminary hazard analysis (PFfA), interface safety analysis (ISA), and job safety analysis (JSA). Patient safety basics are presented in Chapter 5. This chapter covers such topics as patient safety goals, causes of patient injuries, patient safety culture, factors contributing to pahent safety culture, safe practices for better health care, and patient safety indicators and their selection. 

The centerpiece of JCAHO s new approach to sentinel events under Accreditation Watch was root cause analysis (RCA)—the process of continually asking why questions to uncover hidden, underlying causes of harm and near misses. At that point, a final procedure had not yet been developed for conducting RCAs, so the RCA on the baby s death was undertaken in close collaboration with JCAHO. The hospital leadership set the tone and supported a system-oriented, blame-free approach as the analysis was conducted in a two-month multi-step iterative process. The analysis was long, tedious, and worthwhile. 

In each incident you should ask yourself (1) What happened (2) How did it happen (3) Why did it happen This series of questions is one form of root cause analysis (RCA), a standard procedure in the investigation of incidents in business and industry. The last question is the most important one and you will find you may have to ask and answer this question several times in sequence before you come close to the real or root causes of an incident. RCA generally recommends asking Why five times to get to a fundamental, rather than superficial, cause. Root causes are the basic causes of an incident that can be reasonably identified, that can be controlled, and for which recommendations or lessons learned can be derived. Many times root causes are not immediately obvious, but can be identified from careful inquiry. Once you know the root causes you should be able to develop recommendations or steps to prevent this from happening again. 

The way in which Root Cause Analysis (RCA) and a Corrective and preventive action system (CAPA) can be used to improve quality is given by the statement from GMP Chap. 1 Pharmaceutical quality system ... 

Root-cause analysis (RCA) is meant to identify the root-cause of an important incident, in order to be able to take measures to prevent recurrence of the incident. 

To effectively integrate these approaches, some form of overarching process is required to provide a framework which will guide the user to conduct the most appropriate form of analysis. One option for such a structure is Root Cause Analysis (RCA). The process of conducting RCA is such that the incident is investigated from the top down, progressively revealing more details of the causes. 

American Society for Quality, What is Root Cause Analysis (RCA) , http //www.asq.org/leam-about-quality/root-cause-analysis/overview/ overview.html, (accessed Jul 2015) Root cause analysis, https //en. m.wikipedia.org/wiki/Root cause analysis, (accessed Jul 2015). Robert Hill, Personal account of an incident 12. Haim Weizman, Chemistry Department, University of CaUfornia San Diego, Why 1 always wear a lcU> coat , https //www.youtube. com/watch v=a6DrCdjedas, (accessed Feb 2015)... 

Root cause analysis (RCA) of adverse surgical outcomes is used in high-lia-bility industries, but still not widely applied to analyze and resolve and improve adverse medical outcomes. Conventional RCA works linearly and backwards to identify root causes with limitations by the traditionally deterministic thinking, creating bias. In contrast, simulation RCA places the investigation in the context... 

The prototype for the sequential accident model is the Domino model. The Domino model represents simple, linear causahty, as in the case of a set of domino pieces that fall one after the other. According to the logic of this model, the purpose of event analysis is to find the component that failed, by reasoning backwards from the final consequence. This corresponds in all essentials to the principle of the Root Cause Analysis (RCA), which will be described in more detail in the following. Similarly, risk analysis looks for whether something may break, meaning... 

Root cause analysis (RCA) It includes everything the RCI covers plus the minor human error causes and, more importantly, the management system problems that allow the human errors and other system weaknesses to exist. An RCA can sometimes extend to sites other than the one involved in the original problem. 

The shift from reactive corrective maintenance toward proactive predictive maintenance represents a significant move toward enhanced reliability. However, efforts designed to identify problems before failure are not sufficient to optimize reliability levels. Ultimately, for enhanced reliability, the root causes of maintenance problems have to be determined, in order to eliminate them. The high-est-priority use of root cause analysis (RCA) should be for chronic, recurring problems (often in the form of small events), since these usually consume the majority of maintenance resources. Isolated problems can also be analyzed by RCA. 

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