Use root cause analysis to understand and improve process safety culture

2008 ◽  
Vol 27 (4) ◽  
pp. 274-279 ◽  
Author(s):  
Ian S. Sutton
Keyword(s):  
Safety Culture ◽  
Root Cause Analysis ◽  
Process Safety ◽  
Cause Analysis ◽  
Root Cause

scholarly journals Assessment of Latent Factors Contributing to Error: Addressing Surgical Pathology Error Wisely

2011 ◽  
Vol 135 (11) ◽  
pp. 1436-1440 ◽  
Author(s):  
Maxwell L. Smith ◽  
Stephen S. Raab
Keyword(s):  
Safety Culture ◽  
Root Cause Analysis ◽  
Near Miss ◽  
Surgical Pathology ◽  
Latent Factors ◽  
Cause Analysis ◽  
Root Cause ◽  
Event Frequency ◽  
Latent Components ◽  
Gross Examination

Context.—Methods to improve surgical pathology patient safety include measuring the frequency of error in specific steps of the surgical pathology testing process, root cause analysis of active and latent components, and implementation of quality improvement initiatives. Objective.—To determine the frequency and cause of near-miss events in the specimen accessioning, setup, and biopsy-only gross examination testing steps of anatomic pathology. Design.—We used an observational checklist method to identify near-miss events. We performed root cause analysis to determine latent factors contributing to near-miss events. We conducted observations for 45 hours during 5 days, involving the accessioning and processing of 335 specimens. Results.—We detected a total of 2310 process-dependent and 266 operator-dependent near-miss events, resulting in a near-miss–event frequency of 5.5 per specimen. Root cause analysis showed that all process and operator near-miss events were associated with multiple system latent factors, including lack of standardized protocols, appropriate knowledge transfer, and focus on safety culture. Conclusion.—We conclude that the increased focus on surgical pathology near-miss events will reveal latent factors that may be targeted for improvement.

Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers

2017 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Bastien Boussat ◽  
Arnaud Seigneurin ◽  
Joris Giai ◽  
Kevin Kamalanavin ◽  
José Labarère ◽  
...  
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Hospital Care ◽  
Patient Safety Culture ◽  
Root Cause Analysis ◽  
Care Providers ◽  
Cause Analysis ◽  
Root Cause

Can Safety Culture Be This Important?

2014 ◽  
Author(s):  
Dorian S. Conger
Keyword(s):  
Organizational Culture ◽  
Opposite Direction ◽  
Safety Culture ◽  
Evaluation Process ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Critical Questions ◽  
Root Cause ◽  
The People ◽  
Organizational Culture Change

Organizational culture has been extensively studied since the 1950’s. The research consistently demonstrates that an organization’s culture has a direct and immediate impact on the behaviors of the people working within the organization. For many years, the culture of an organization was not a part of the evaluation process when performance deficiencies or incidents were evaluated. In some instances, organizations were even told specifically that such ‘soft’ issues were not to be considered. Now, it seems that the pendulum has swung completely in the opposite direction. Organizations are encouraged and sometimes even required to consider safety culture contributions to performance problems and accidents/incidents. Few systematic methods exist to evaluate the contributions of safety culture to incident and accidents as part of a root cause analysis. This paper explores several questions related to the importance of safety culture and how it can be evaluated and changed for the betterment of the organization(s) involved. Some of the critical questions are: 1) How is it possible that safety culture has become so important in evaluating the performance of an organization? 2) Whether in terms of deficiencies or accident/incidents — can safety culture be reliably measured, particularly during a root cause analysis? 3) If it can be measured, how can it be changed? 4) Does organizational culture change have to take years to accomplish?

Root Cause analysis of SG tube ODSCC indications within the tube sheets of NPP biblis unit A

2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Rule Construction and its Execution for Root Cause Analysis

2012 ◽  
Vol 132 (10) ◽  
pp. 1689-1697
Author(s):  
Yutaka Kudo ◽  
Tomohiro Morimura ◽  
Kiminori Sugauchi ◽  
Tetsuya Masuishi ◽  
Norihisa Komoda
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause
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