scholarly journals Our First Review: An Evaluation of Effectiveness of Root Cause Analysis Recommendations in Hong Kong Public Hospitals

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) 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.

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

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.

Near-Realtime Server Reboot Monitoring and Root Cause Analysis in a Large-Scale System

2021 ◽  
Author(s):  
Fred Lin ◽  
Bhargav Bolla ◽  
Eric Pinkham ◽  
Neil Kodner ◽  
Daniel Moore ◽  
...  
Keyword(s):  
Large Scale ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Large Scale System ◽  
Root Cause

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

2015 ◽  
Vol 60 ◽  
pp. 160-169 ◽  
Author(s):  
Marc Schaaf ◽  
Gwendolin Wilke ◽  
Topi Mikkola ◽  
Erik Bunn ◽  
Ilkka Hela ◽  
...  
Keyword(s):  
Large Scale ◽  
Root Cause Analysis ◽  
Telecommunications Networks ◽  
Cause Analysis ◽  
Root Cause

scholarly journals ANALISIS RISIKO KESELAMATAN KERJA PADA PROYEK PENGEMBANGAN BANDARA INTERNASIONAL JUANDA TERMINAL 2 SURABAYA

IKESMA ◽  
2017 ◽  
Vol 13 (2) ◽  
Author(s):  
Reny Indrayani
Keyword(s):  
Risk Assessment ◽  
Root Cause Analysis ◽  
Risk Identification ◽  
Occupational Accidents ◽  
Observational Research ◽  
Cross Sectional ◽  
Cause Analysis ◽  
Safety Issues ◽  
Overtime Work ◽  
Root Cause

The construction sector played an important role in development and was the biggest contributor of work accident rate in Indonesia. The aim of the research were to analyze human, methods, machines, materials, and environment element as cause of occupational accidents. This was a cross-sectional observational research conducted in October 2012 to March 2013. This research was carried out with several integrates stages which include risk identification, risk assessment and priorities formulation, root cause analysis, and ended by recommendations for controlling risk and hazard. Risk identificationshowed that there were 100 risks that couldthreaten the workers. The following categories were: 4% low risk categories, 48% moderate risk, 39% high risk, and 9% extreme risk. Through the Q sort technique obtained five priority safety issues: workers falling from height, electric shock, workers stung by material lifted, fires or explosions, and the scaffolding collapsed. Based on root cause analysis, it showed that the most likely root cause of the problems was dominated by the human factor such as: fatigue due to overtime work, lack of experience and understanding of the procedure, lack of awareness of the importance of the ocupational safety and health. Keywords: construstion,risk assessment, root cause.

scholarly journals Root Cause Analysis of Large Scale Application Testing Results

Informatica ◽  
2016 ◽  
Vol 27 (4) ◽  
pp. 819-842 ◽  
Author(s):  
Rūdolfs Opmanis ◽  
Paulis Ķikusts ◽  
Mārtiņš Opmanis
Keyword(s):  
Large Scale ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

scholarly journals Are Hospital Chaplains Under Stress in Hong Kong? Preliminary Results from a Pilot Study

Religions ◽  
2019 ◽  
Vol 10 (5) ◽  
pp. 325
Author(s):  
Leung Andrew Luk
Keyword(s):  
Hong Kong ◽  
Cross Sectional Study ◽  
Public Hospitals ◽  
Background Information ◽  
Healthcare Team ◽  
Spiritual Experiences ◽  
Cross Sectional ◽  
Hospital Chaplains ◽  
Daily Spiritual Experience Scale ◽  
Great Stress

In Hong Kong, healthcare professionals are under great stress when performing their duties in public hospitals, in which patient beds are usually fully occupied, and the workload is high. Hospital chaplains are members of the healthcare team in a hospital, as well: Are they also under stress? Furthermore, is there any relationship between religious experience and stress? This study aims to provide some background information about the health status of hospital chaplains, and to explore any relationships between stress and their spiritual experiences. A total of 100 hospital chaplains were invited to participate in this cross-sectional study, and a 60% valid response rate was obtained. Participants completed the Depression, Anxiety and Stress Scale 21 and the Daily Spiritual Experience Scale. The results showed that most of the hospital chaplains (78.3%) have a normal stress level, and the prevalence of mild to severe symptoms of stress is low (21.7%) when compared with the stress levels of nurses (41.1%) found in another study. However, more anxiety was expressed by younger hospital chaplains; this is common in caring professions, and they should have mentoring and support. All hospital chaplains have a higher level of spiritual experiences, which was not found to be related to stress.

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