Value and Cost Effectiveness of Conducting a Root Cause Analysis

2012 ◽  
Author(s):  
André-Michel Ferrari ◽  
Brad Jones
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Team Members ◽  
Root Cause ◽  
Effective Manner ◽  
Knowledge Enhancement ◽  
Primary Driver ◽  
The Cost

The formal Root Cause Analysis (RCA) process consists of a structured approach to identifying the underlying factors that result in the unwanted outcomes of one or more typically negative past events (chronic or sporadic). The process helps to identify what systems or behaviors need to be modified to prevent recurrence of similar outcomes. The fundamental driver of the RCA is to eliminate the causes that lead to the unwanted event rather than addressing the symptoms of the event. This generally leads to multiple corrective actions rather than a single solution. Based on various root causes analyses conducted by a department in Enbridge Pipelines since 2006, various benefits provided by RCA exercises are highlighted in this paper. The findings were mainly derived from completed RCAs as well as RCA team member surveys. Firstly, the cost effectiveness of the RCA process was identified as a primary driver for this exercise. For example, one RCA involving a multidisciplinary team of 8 members, costing approximately $35,000, led to $1M in recommended solutions generating $16M in potential savings. In other words, each of the 350 hours spent on the RCA produced $8,571 in savings underlining the value creation to the company. Secondly, the RCA process combined with the power of the team reflection led to the identification of new issues which were causing other revenue losses to the company. Because these issues were not part of the defined scope of the original RCA, their root causes were not be immediately assessed but nevertheless their impact could easily be quantified and forwarded to Management for review. The third benefit highlighted by RCAs is more of an educational benefit to team members and subsequently the organization. Through cross functional examination of the issues and events, the team members became aware and educated on issues that would not have otherwise been apparent. Additionally, by working through the RCA methodology, the team members enhanced their problem solving abilities which benefit their everyday work. In conclusion, other than identifying techniques to preclude unwanted outcomes and providing cost saving opportunities in a very cost effective manner, RCAs can be considered as an effective knowledge enhancement tool for an organization.

Efficacy and Cost-Effectiveness of a Limited Phenotype Matching Transfusion Protocol for Children with Sickle Cell Disease

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 3043-3043
Author(s):  
Jerry E Squires ◽  
Vinu Jyothi ◽  
Sherron M. Jackson ◽  
Miguel Abboud ◽  
Ram Kalpatthi
Keyword(s):  
Cost Effectiveness ◽  
Sickle Cell ◽  
Cost Effective ◽  
Red Cells ◽  
Red Cell ◽  
Phenotype Matching ◽  
Screening Programs ◽  
Red Cell Antigens ◽  
Effective Manner ◽  
The Cost

Abstract Alloimmunization to red cell antigens can seriously compromise the treatment of chronically transfused sickle cell patients by increasing the risk of delayed hemolytic transfusion reactions and decreasing the availability of suitable red cell units. In an effort to reduce the rate of alloimmunization, many institutions routinely provide transfusions that are phenotypically matched for selected red cell antigens. Controversy exists in this approach with some advocating the use of extensive matching protocols in which 9 or more red cell antigens are screened while others follow a more limited approach in which only 3–5 antigens are screened. Neither the relative clinical efficacy nor the cost-effectiveness of these approaches has been compared. In our institution a limited phenotype matching program was instituted in June 1999 in which red cells provided to all pediatric sickle cell patients are negative for C, E, and Kell antigens only. All patients are screened for the presence of red cell allo-antibodies prior to each transfusion and additional phenotype matching was performed for patients who develop specific antibodies other than C, E and/or Kell. We present here our experience with this limited phenotype matching approach in 169 pediatric sickle cell patients. The patients in our study have received a mean of 100.7 red cell transfusions (range 1–555). Overall, 36 (21.3%) patients developed at least one red cell alloantibody. However, 15 of these patients had developed antibodies to C, E, or Kell (or a combination) as a result of transfusion prior to referral to our hospital or as a result of transfusion here, prior to the routine implementation of our limited matching program. Therefore, only 21 patients (12.4%) developed red cell alloantibodies that could not be prevented by the consistent use of our protocol. These antibodies include; Jka (4), M (4), Fya (3), S (3), Cw (3), Lua (3), V (2), Jsa (2), and Lea, Leb, Kpa, Kna, Jkb, c (1 each). The rate of antibody production was 0.17/100 units transfused. Our results favorably compare with other reports of more extensive phenotypic matching programs (e.g, 6.7% of patients with red cell alloantibodies; 0.06 antibodies/100 units transfused). In addition, only 6 of our patients (3.6%) developed multiple (non-C, E, Kell) allo-antibodies. In 3 of these patients the antibodies developed were of questionable clinical significance (Lea, Leb, Kna) or would generally not be screened even in the most thorough phenotype matching program (Cw, Lua). Among our patients with multiple alloantibodies, compatible red cell units were easily available with 4–13% of ABO/Rh compatible units collected from a non-ethnically selected population being suitable. The extended screening carried out for this limited number of patients (3.6%) is a far more cost-effective and sustainable approach for a large sickle cell treatment program than would be possible with an extended phenotyping program including essentially all patients. It should be noted that none of our patients have demonstrated clinical evidence of either acute or delayed hemolysis. Finally, it is important to consider the relative cost-effectiveness of various phenotype matching protocols. At an approximate cost of $200 for each red cell unit and a fee of $85 for each additional antigen screened by our local blood supplier, each unit of red cells for our patients costs $455. In screening programs requiring more extensive matching (8–9 antigens screened) the cost per unit would be almost double this amount ($880–$965). Our study suggests that this limited antigen matching is effective in reducing alloimmunization in chronically transfused pediatric sickle cell patients and additionally does so in a more cost-effective manner than more extensive screening programs. Finally, even in those patients who ultimately developed red cell antibodies, the availability of suitable red cell products was never seriously compromised.

Wire-Wound Resistor Investigation—A Case Study

2016 ◽  
Author(s):  
Jason Wheeler ◽  
John Wolfgong
Keyword(s):  
Failure Analysis ◽  
Root Cause Analysis ◽  
Interesting Case ◽  
Cause Analysis ◽  
Root Cause ◽  
Resistive Element ◽  
Primary Driver ◽  
Mission Critical ◽  
Corrective Actions

Abstract The focus of this paper is to present an interesting case study involving Vishay wire-wound (WSC model) resistor failures, which affected a significant number of production and fielded assemblies. The failures were considered “mission critical”, which was the primary driver necessitating root cause analysis. A disciplined approach to the failure analysis effort was established, which resulted in root cause determination and the generation of appropriate corrective actions. This paper will highlight a non-conventional decapsulation method used to preserve the integrity of the fragile resistive element and a “lucky break” that was instrumental in linking the supplier’s actions to the failures.

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

Root Cause Analysis Techniques Using Picosecond Time Resolved LADA

2014 ◽  
Author(s):  
Dan Bodoh ◽  
Kent Erington ◽  
Kris Dickson ◽  
George Lange ◽  
Carey Wu ◽  
...  
Keyword(s):  
Integrated Circuits ◽  
Picosecond Laser ◽  
Root Cause Analysis ◽  
Fault Isolation ◽  
Time Resolved ◽  
Cause Analysis ◽  
Root Cause ◽  
Design And Manufacturing ◽  
Multiple Interactions ◽  
Established Technique

Abstract Laser-assisted device alteration (LADA) is an established technique used to identify critical speed paths in integrated circuits. LADA can reveal the physical location of a speed path, but not the timing of the speed path. This paper describes the root cause analysis benefits of 1064nm time resolved LADA (TR-LADA) with a picosecond laser. It shows several examples of how picosecond TR-LADA has complemented the existing fault isolation toolset and has allowed for quicker resolution of design and manufacturing issues. The paper explains how TR-LADA increases the LADA localization resolution by eliminating the well interaction, provides the timing of the event detected by LADA, indicates the propagation direction of the critical signals detected by LADA, allows the analyst to infer the logic values of the critical signals, and separates multiple interactions occurring at the same site for better understanding of the critical signals.

Root Cause Analysis for Pin Leakage

2016 ◽  
Author(s):  
Zhigang Song ◽  
Jochonia Nxumalo ◽  
Manuel Villalobos ◽  
Sweta Pendyala
Keyword(s):  
Failure Analysis ◽  
Root Cause Analysis ◽  
Advanced Technology ◽  
Process Step ◽  
Cause Analysis ◽  
Hard Mask ◽  
Technology Node ◽  
Root Cause ◽  
Tools And Techniques

Abstract Pin leakage continues to be on the list of top yield detractors for microelectronics devices. It is simply manifested as elevated current with one pin or several pins during pin continuity test. Although many techniques are capable to globally localize the fault of pin leakage, root cause analysis and identification for it are still very challenging with today’s advanced failure analysis tools and techniques. It is because pin leakage can be caused by any type of defect, at any layer in the device and at any process step. This paper presents a case study to demonstrate how to combine multiple techniques to accurately identify the root cause of a pin leakage issue for a device manufactured using advanced technology node. The root cause was identified as under-etch issue during P+ implantation hard mask opening for ESD protection diode, causing P+ implantation missing, which was responsible for the nearly ohmic type pin leakage.

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