Our Root Cause Analysis Process

2015 ◽  
pp. 5-14
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process

scholarly journals Early Engagement of Residents Into the Root Cause Analysis Process

2016 ◽  
Vol 8 (3) ◽  
pp. 459-460 ◽  
Author(s):  
Miriam Bar-on ◽  
Ross P. Berkeley
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process

scholarly journals Employing a Root Cause Analysis Process to Improve Examination Quality

2019 ◽  
Vol 94 (1) ◽  
pp. 71-75 ◽  
Author(s):  
Sally A. Santen ◽  
Karri L. Grob ◽  
Seetha U. Monrad ◽  
Caren M. Stalburg ◽  
Gary Smith ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process ◽  
Examination Quality

Root Cause Analysis of Glovebox Glove Failure

2007 ◽  
Author(s):  
Y. H. Park ◽  
Michael Cournoyer
Keyword(s):  
Safety Concern ◽  
National Laboratory ◽  
Root Cause Analysis ◽  
Nuclear Materials ◽  
Alamos National Laboratory ◽  
Cause Analysis ◽  
Los Alamos National Laboratory ◽  
Root Cause ◽  
Analysis Process

The Nuclear Materials Technology (NMT) Division has the largest inventory of glovebox gloves at Los Alamos National Laboratory (LANL). Consequently, the minimization of unplanned breaches of the glove material, typically resulting in glove failures, is a significant safety concern in the daily operations in NMT Division facilities. To investigate processes and procedures that minimize unplanned breaches in the glovebox, information on glovebox glove failures has been compiled from formal records and analyzed using statistical methods. Based on these research results, the next step of the research is to identify root causes of glove failures and the actions adequate to prevent recurrence. In this paper, root cause analysis was conducted for a cleanup breach case study to demonstrate the computerized root cause analysis process. Based on analysis results, effective recommendations were generated.

Hamilton Acute Pain Service Safety Study

2014 ◽  
Vol 120 (1) ◽  
pp. 97-109 ◽  
Author(s):  
James E. Paul ◽  
Norman Buckley ◽  
Richard F. McLean ◽  
Karen Antoni ◽  
David Musson ◽  
...  
Keyword(s):  
Acute Pain ◽  
Root Cause Analysis ◽  
Acute Pain Service ◽  
Patient Controlled Analgesia ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process ◽  
Severe Hypotension ◽  
Before And After ◽  
Address System

Abstract Background: Although intravenous patient-controlled analgesia opioids and epidural analgesia offer improved analgesia for postoperative patients treated on an acute pain service, these modalities also expose patients to some risk of serious morbidity and even mortality. Root cause analysis, a process for identifying the causal factor(s) that underlie an adverse event, has the potential to identify and address system issues and thereby decrease the chance of recurrence of these complications. Methods: This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals, before and after the introduction of a formal root cause analysis process. The “before” cohort included all patients with pain from February 2002 to July 2007. The “after” cohort included all patients with pain from January 2009 to December 2009. Results: A total of 35,384 patients were tracked over the 7 yr of this study. The after cohort showed significant reductions in the overall event rate (1.47 vs. 2.35% or 1 in 68 vs. 1 in 42, the rate of respiratory depression (0.41 vs. 0.71%), the rate of severe hypotension (0.78 vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.0 vs. 0.08%). Associated with these results, the incidence of severe pain increased from 6.5 to 10.5%. To achieve these results, 26 unique recommendations were made of which 23 being completed, 1 in progress, and 2 not completed. Conclusions: Formal root cause analysis was associated with an improvement in the safety of patients on a pain service. The process was effective in giving credibility to recommendations, but addressing all the action plans proved difficult with available resources.

scholarly journals A Framework for Modern Risk-Informed Root Cause Analysis Process

2020 ◽  
Vol 14 (7) ◽  
Author(s):  
Dorian Conger ◽  
Ivan Vrbanic ◽  
Ivica Basic
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process

The Importance of Effective Root Cause Analysis of Failures in High Reliability Microelectronics Applications: A Case Study

2014 ◽  
Vol 2014 (1) ◽  
pp. 000493-000499
Author(s):  
Gwen Schulz
Keyword(s):  
High Reliability ◽  
Organizational Factors ◽  
Root Cause Analysis ◽  
Metal Particles ◽  
Cause Analysis ◽  
Root Cause ◽  
Analysis Process ◽  
Component Supplier ◽  
Microelectronic Components

The screening and detection of failures in high reliability electronics is crucial to mission success. The governing standards for microelectronic components prescribe effective screens to address known failure modes during the manufacture of the components. When failures are detected outside of the normal component screening process such as in the next higher assemblies, the analysis of such failures to root cause is even more crucial. Effective root cause analysis requires collaboration among personnel having expertise in many areas, both technical and organizational. Too often, the analysis stops at the ‘how’ a part failed, rather than the ‘why’ and true root cause determination. Failures may not only represent defects in the technical aspects of the design, materials or application of the hardware, but may also be related to human organizational factors such as the competing interests of time, quality and cost. The analysis must extend beyond the forensic data into the human organization and the interaction between people, process and hardware. In this paper, the author illustrates an effective root cause corrective action (RCCA) analysis process through the discussion of a microelectronics packaging case study. The case involved failure of high reliability hybrid microelectronic components at the next higher assembly level. The case study provides insights into the root cause analysis process as well as awareness that component level high reliability screening is not impervious. It is critical for the next level user to have the expertise in their organization to understand both the how and the why of such failures. The case study describes a failure related to loose metal particles inside a hermetically sealed multilayer ceramic package which had passed Particle Impact Noise Detection (PIND) screening at the supplier. Root cause analysis determined the cause for the screening escape as well as the cause of the metal particles, and effective corrective actions were implemented at both the component supplier and Honeywell. Technical causes include improper package design, weld schedule and screening methods. Organizational causes include inadequate documentation, lack of training and failure to react to prior failures. The root cause investigation team was a multi-discipline group from Honeywell, our customer, and the component supplier, with additional consulting input from other suppliers, equipment manufacturers and industry experts.

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