Root cause coding

When the diagram is complete, the analyst proceeds through it to identify sets of events that were critical in the accident sequence. These critical events are then subjected to a further causal analysis using other techniques such as root cause coding, described below in Section 6.8.4. 

The events and causal factors chart for this incident is shown in Figure 7.9. The primary sequence of events is shown horizontally in bold boxes. Secondary events are shown in the other boxes, and conditions are in ovals. From the diagram three causal factors were identified and carried forward to the Root Cause Coding to establish the root causes of the causal factors. 

Causal Factor 1 Operator A Connects Pump to 21A Pipe Not 12A Pipe Root cause coding identified the following root causes ... 

Root cause coding identified the following root causes ... 

Thorough documentation of medication errors provides information about the severity of the error as it relates to the effeet on the patient, the product(s) involved, the competence of staff handling the produet or proeessing the order, any contributing factors that may predispose a product to misuse, and the suspected root cause of the error. USP adds certain codes to MER Program data in order to characterize the error as it was reported. These codes include the type of error and the possible eause(s) of error. The following list shows some of the produet eharaeteristics that have been recorded over 9 years to have caused or eontributed to a medication error. 

GGC codes for glycine GTC codes for valine. It turns out that the corresponding position in the Ras protein is 12. So replacement of Gly by Val in Ras is a root cause of carcinogenesis. As it turns out, replacement of this glycine residue by any other residue in Ras generates an oncoprotein. Clearly, Gly is critical to the function of this protein, about which more follows below. 

Multiple layers of protection are a concept incorporated in the American Chemistry Council Process Safety Code of Management Practices. ) Management Practice number 15 endorses sufficient layers of protection through technology, facilities, and personnel to prevent escalation from a single failure to a catastrophic occurrence. This approach can be applied to multiple system root causes when the investigation team evaluates... 

The US Department of Veterans Affairs National Center for Patient Safety (NCPS) of the US Department of Veterans Affairs, which developed a new root cause analysis model to be used in the healthcare system consisting of assigning a safety assessment code to prioritise... 

A software component designed and coded either manually or with the help of tools may be subject to a wide variety of faults. The root cause of these faults is to be found in the specification, in the design or in the implementation. A software fault can be seen as a deviation in the content and/or in the order of instructions or data stored in memory causing the microprocessor not to behave as expected under some event or sequences of events. Trying to consider all possible faults that could affect even a simple software component is not practicable. Nevertheless, it is possible to consider the consequences of such faults, as they will lead to a few numbers of software failure modes... 

If some regression or unit tests fail, they sometimes do not give sufficient information to tell immediately what is the root cause of the issue. In that case running the faulting tests on manually or automatically instrumented executable code might provide more data and point more directly to the actual bug. 

Ensure compliance with safety and lire regulatory standards and codes Participate in organizational root cause analysis sessions as necessary to identify causal factors... 

The integrated issues management system shall have a mechanism similar to that required in the commercial nuclear industry under Title 10 of the Code of Federal Regulations (CFR) Part 50.59 to define the significance of an issue or condition to personnel/reactor safety. The system shall also provide a mechanism to determine the root cause of the condition, the remedial corrective action(s) or compensatory measure(s) to be taken, and action(s) to prevent recurrence. The results of such evaluations shall be provided to senior contractor management for review and transmission to the DOE. 

A form of salt loss in infancy was long considered to be due to renal tubules that were refractory to aldosterone. Recent studies have described variant roots of the condition, either mutations in the mineralocorticoid receptor, the genes coding the epithelial sodium channel (ENaC), or other causes [6]. Many infant patients recover spontaneously, probably due to maturation of proximal tubular function. 

---