Human Error Root Cause Analysis

Root Cause Analysis (RCA) can be an effective proactive methodology to forecast or predict probable events even before they occur. It’s use has been embraced by regulators and can be found in the most advanced management tools such as the recently published ISO 55000 series of international management standards for asset management. An RCA identifies both the obvious and the underlying causes of an event so that specific solutions can be implemented. A complete RCA consists of a clear definition of the issue, a thorough analysis supported with evidence and a specific action plant for implementing solutions. In this respect, what may have appeared as a material failure or “human error,” can often be shown to be the result of an inadequate infrastructure management systems or the failure of management processes. Generally thought of as a reactive method of identifying the causes of past incidents, this paper will describe the elements of an RCA and how it can be a powerful tool to identify systems or behaviors that when modified or corrected, will prevent recurrence of similar outcomes.

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The Role of Human Error in Root Cause Analysis: Understanding Human Behavior

Root Cause Analysis ◽

10.1201/9780429446573-12 ◽

2019 ◽

pp. 221-252

Author(s):

Mark A. Latino ◽

Robert J. Latino ◽

Kenneth C. Latino

Keyword(s):

Human Behavior ◽

Human Error ◽

Root Cause Analysis ◽

Cause Analysis ◽

Root Cause

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Multiple Systemic Contributors versus Root Cause

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/1541931213601060 ◽

2016 ◽

Vol 60 (1) ◽

pp. 264-264 ◽

Cited By ~ 1

Author(s):

Katherine E. Walker ◽

David D. Woods ◽

Michael F. Rayo

Keyword(s):

Adverse Events ◽

Human Error ◽

Space Station ◽

Root Cause Analysis ◽

Near Miss ◽

Specific Sequence ◽

Cause Analysis ◽

Extravehicular Activity ◽

Root Cause ◽

Sequence Of Events

In 2013 NASA nearly drowned an astronaut during an Extravehicular Activity (EVA 23) on the International Space Station due to spacesuit water leakage. Indicators of trouble on the preceding EVA (22) were discounted. NASA carried out an investigation of the near miss event that is a sample of how root cause analysis is carried out in actual organizations (National Aeronautics and Space Administration, 2013). This paper contrasts the root cause analysis with a new analysis the authors carried out that captures how multiple systemic contributors combined to create the conditions that led up to the near miss. The new analysis illustrates the original finding from the late 1980s that accidents arise from multiple factors each necessary but only jointly sufficient (Reason, 1990; Woods, 1990; Cook, 2000; Woods, Dekker, Cook, Johannesen, & Sarter, 2010). Many of these contributors are system factors that have been present (latent) in the organization for some time prior to the specific sequence of events. In other words, the accidents arose from organizational or systemic factors (Reason, 1997). In contrast, the traditional root cause analysis focuses on the human roles closest to the adverse event and only raises systemic issues in terms of vague generalities that are difficult to address in systemic improvements (Dekker, 2014; Woods et al., 2010). The paper provides this contrast for two purposes. The first goal of this paper is to provide a concrete technique and diagram for identifying systemic contributors to adverse events (Systemic Contributors Analysis and Diagram or SCAD). The second goal is to highlight how the current practice of root cause analysis is unable to come to grips with systemic issues, misses the interactions between contributors, and misses emergent system properties. Using this systemic technique reveals that adverse events are very often due to production pressure at the blunt end, not human error at the sharp end of systems.

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How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

Medical Principles and Practice ◽

10.1159/000508677 ◽

2020 ◽

Vol 29 (6) ◽

pp. 524-531

Author(s):

Jimmy Martin-Delgado ◽

Alba Martínez-García ◽

Jesús María Aranaz ◽

José L. Valencia-Martín ◽

José Joaquín Mira

Keyword(s):

Systematic Review ◽

Patient Safety ◽

Human Error ◽

Root Cause Analysis ◽

Care Process ◽

Cause Analysis ◽

Root Cause ◽

Communication Problems ◽

Practical Usefulness ◽

Common Causes

Objectives: The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). Methods: A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. Results: Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. Conclusions: RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

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Human Factors in Incident Investigation

Proceedings of the Human Factors Society Annual Meeting ◽

10.1177/154193128903301526 ◽

1989 ◽

Vol 33 (15) ◽

pp. 1024-1028 ◽

Cited By ~ 1

Author(s):

Mark E. Armstrong

Keyword(s):

South Carolina ◽

Human Factors ◽

Human Error ◽

Reporting System ◽

Root Cause Analysis ◽

Savannah River Site ◽

Savannah River ◽

Cause Analysis ◽

Root Cause ◽

River Site

The Savannah River Site (SRS), located in South Carolina, is a key Department of Energy production and research facility for nuclear materials. Incident investigations performed at the Savannah River Site showed the cause of approximately 75% of all operating incidents in non-reactor facilities to be human error. The technical incident reporting system in place required the investigator to list the cause of an incident in broad terms (i.e., Personnel Error, Equipment Error) and to categorize it according to subclassifications (i.e., Operator Error, Supervisor Error, Mechanic Error). The reporting system, using these classifications, tended to emphasize “what happened” during an incident and “who was involved”, instead of getting to the details of “why” an incident occurred. The high rate of human error as the cause of incidents indicated that further analysis was in order. Human factors personnel in the Facility Safety Evaluation Section (FSES - an oversight organization with emphasis on non-reactor facilities) wanted to determine the causes of human error in a way that would identify more precisely why the errors occurred. To satisfy these needs, FSES is implementing a root cause analysis program for SRS. Root cause analysis consists of two parts; the first being Events and Causal Factor (E&CF) Charting; and the second, Root Cause Coding using a Root Cause Tree. The objectives were to provide a systematic method for identifying the root causes of a given incident in order to make detailed recommendations for preventing its recurrence, and to provide a database of incident root causes for identifying problem areas across incidents. Root cause analysis would guide the incident investigator to state “why” an incident occurred using detailed cause codes (e.g., Incomplete Training, Labels Less Than Adequate). Root cause trending would enable FSES to track the causes of human error, recommend solutions, and track corrective actions. FSES developed a one day workshop to train several hundred incident investigators at SRS to perform investigations using the root cause analysis method. This presentation will discuss the development and implementation of the root cause analysis system at SRS by FSES human factors professionals.

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