Towards a Timely Root Cause Analysis for Complex Situations in Large Scale Telecommunications Networks

Abstract Background: To evaluate the effectiveness of root cause analysis (RCA) recommendations and propose possible ways to enhance its quality in Hong Kong public hospitals.Methods: A retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as ‘strong’, ‘medium’ or ‘weak’ strengths utilizing the US’s Veteran Affairs National Center for Patient Safety action hierarchy.Results: A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to ‘training and education’ (466, 61%), ‘additional study/review’ (104, 14%) and ‘review/enhancement of policy/guideline’ (39, 5%).Conclusions: This study provided insights about the effectiveness of RCA recommendations across all public hospitals in Hong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-to-use tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions.

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Root Cause Analysis of Large Scale Application Testing Results

Informatica ◽

10.15388/informatica.2016.113 ◽

2016 ◽

Vol 27 (4) ◽

pp. 819-842 ◽

Cited By ~ 2

Author(s):

Rūdolfs Opmanis ◽

Paulis Ķikusts ◽

Mārtiņš Opmanis

Keyword(s):

Large Scale ◽

Root Cause Analysis ◽

Cause Analysis ◽

Root Cause

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Our First Review in 12 Years: An Evaluation of Effectiveness of Root Cause Analysis in Hong Kong Public Hospitals

10.21203/rs.3.rs-15698/v1 ◽

2020 ◽

Author(s):

Andy Yick Ting Kwok ◽

Alastair Pui Yan Mah ◽

Katherine Mo Ching Pang

Keyword(s):

Hong Kong ◽

Large Scale ◽

Root Cause Analysis ◽

Cross Sectional Study ◽

Public Hospitals ◽

Cross Sectional ◽

Cause Analysis ◽

Root Cause ◽

Review Team ◽

Behavioural Factors

Abstract Background: To evaluate the effectiveness of root cause analysis (RCA) and propose possible ways to enhance its effectiveness in Hong Kong public hospitals. Methods: A retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as ‘strong’, ‘medium’ or ‘weak’ strengths utilizing the US’s Veteran Affairs National Center for Patient Safety action hierarchy. Results: A total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 282 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 658 recommendations identified in the RCA reports with an average of 3.1 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to ‘training and education’ (466, 61%), ‘additional study/review’ (104, 14%) and ‘review/enhancement of policy/guideline’ (39, 5%). Conclusions: This study provided insights about the effectiveness of RCA across all public hospitals in Hong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-to-use tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions.

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Defect Root Cause Analysis in Large Scale Manufacturing System

International Conference on Computer and Computer Intelligence (ICCCI 2011) ◽

10.1115/1.859926.paper29 ◽

2011 ◽

pp. 179-184

Keyword(s):

Large Scale ◽

Manufacturing System ◽

Root Cause Analysis ◽

Cause Analysis ◽

Root Cause

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Causes of delay in Iranian oil and gas projects: a root cause analysis

International Journal of Energy Sector Management ◽

10.1108/ijesm-04-2018-0014 ◽

2019 ◽

Vol 13 (3) ◽

pp. 630-650 ◽

Cited By ~ 3

Author(s):

Rateb Sweis ◽

Alireza Moarefi ◽

Mahmood Hosseini Amiri ◽

Soad Moarefi ◽

Rawan Saleh

Keyword(s):

Large Scale ◽

Oil And Gas ◽

International Energy Agency ◽

Strong Relationship ◽

Oil And Gas Industry ◽

Root Cause Analysis ◽

Energy Agency ◽

Cause Analysis ◽

Content Type ◽

Root Cause

Purpose The international energy agency states that the world’s primary energy needs are expected to grow to 55 per cent until 2030. Therefore, oil and gas industry as the main energy source will be more crucial where building or advancing new capacities is required. Because the reports highlight the delay as a recurring problem, thereby, more in-depth investigation to find out the main contributing causes is needed. Design/methodology/approach Root cause analysis (RCA) was applied to identify, rank, analysis and categorize the main sources of this problem. Findings Based on RCA procedure; Pareto analysis showed that 84.7 per cent of the delay is because: the radar chart indicated no difference in perception of the participants regarding the importance of the root causes, correlation analysis suggested strong relationship among the participants and the cause-and-effect diagram emphasized more on operational, human and equipment categories, which in total account for 51.86 per cent of the delay. Originality/value The risk planners of large-scale projects can consider these root causes as the main items to analysis, monitor and control, as they are vitally important for project success.

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