scholarly journals Root cause analysis – what do we know?

2021 ◽  
Vol 95 (1/2) ◽  
pp. 87-93 ◽  
Author(s):  
Wendy Groot
Keyword(s):  
Adverse Events ◽  
Audit Quality ◽  
Opportunity To Learn ◽  
Root Cause Analysis ◽  
Policy Makers ◽  
Cause Analysis ◽  
Root Cause ◽  
Audit Firms ◽  
The Future ◽  
Blame Culture

Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective RCA process. Based on the RCA literature, I argue that audit firms would benefit from a systems-based approach and establishing a no-blame culture.

scholarly journals Root cause analysis applied to the investigation of serious untoward incidents in mental health services

2004 ◽  
Vol 28 (3) ◽  
pp. 75-77 ◽  
Author(s):  
L. A. Neal ◽  
D. Watson ◽  
T. Hicks ◽  
M. Porter ◽  
D. Hill
Keyword(s):  
Mental Health ◽  
Mental Health Services ◽  
Health Services ◽  
Adverse Events ◽  
Root Cause Analysis ◽  
Serious Adverse Events ◽  
Cause Analysis ◽  
Root Cause ◽  
Department Of Health ◽  
Investigative Process

The Department of Health publication Building a Safer NHS for Patients sets out the Government's plans for promoting patient safety (Department of Health, 2001). This follows growing international recognition that health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events occurring in health care settings. These plans include a commitment to replace the procedures set out in the Department of Health circular HSG(94)27. This guidance details the methods for investigating every homicide (and some suicides) by patients in current or recent contact with specialist mental health services. Part of the process to modernise HSG(94)27 includes a plan to build expertise within the National Health Service (NHS) in the technique of root cause analysis. This investigative process was developed in industry to identify causal or systems factors in serious adverse events.

Learning From Root Cause Analysis (RCA) Actions That Use Standardization to Address Patient Safety Concerns

2021 ◽  
Vol 10 (1) ◽  
pp. 281-285
Author(s):  
Helen J.A. Fuller ◽  
Tim Arnold ◽  
Tandi M. Bagian
Keyword(s):  
Patient Safety ◽  
Decision Support ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Safety Concerns ◽  
Root Cause ◽  
The Future

Standardization has obvious benefits, but standardization also has clear risks. This paper grew out of an ongoing discussion of how we are standardizing in healthcare today, with a goal of looking to the future for possible improvements. We continue this dialog by describing Root Cause Analysis (RCA) actions involving standardization with hopes of promoting inquiry into the nuances of standardization in different contexts. Studies are needed to understand the benefits and risks of standardization, locally and nationally, as well as the different interpretations of the term “standardization.” These in turn can inform the development of decision support and systems or guidance for facilitating responsible and safe standardization in healthcare. Approaching standardization thoughtfully, not as a blanket solution, but instead as a potential instrument that must be studied, tailored, and cautiously applied could be the next standard we seek.

Multiple Systemic Contributors versus Root Cause

2016 ◽  
Vol 60 (1) ◽  
pp. 264-264 ◽  
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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