Root Cause Analysis (RCA)
the 5 whys?
five questions need to be asked until the real cause is identified
General Oversimplications
human error, equipment failure, procedure not followed, inadequate training, design error, poor communication -surface problems
RCA manageability should be *
root cause analysis should lead to controllable, manageable or adjustable processes. *
what does Root refer too?
the underlying cause
Just Culture advantages
-"safe harbor" people are more likely to come forward -promotes transparency -Encourages a culture of constant quality improvement
Mistakes made during laboratory analysis of casework is considered
Brady material
Just Culture
Culture in which front line operators and others are not punished for actions but where management seeks to learn whether and to what extent the system contributed to the mistake
Fish-bone diagram includes
Equipment, Process, People, Materials/Measurements, Environment, and Management to lead to effect
what is RCA?
Root cause analysis, a wide range of approaches, tools, and techniques used to uncover causes of problems.
Goal of RCA
Look beyond surface to ID problem to Prevent from occuring
Near Miss
Nonconformity with potential to cause damage; damage prevented
Who needs to know when an error occurs?
Stakeholders Technical laboratory management Nontechnical laboratory management
levels of RCA
Symptom (obvious) , visible problem, 1st level, higher level and Root Cause (highest level)
questions asked during RCA investigation
What were we doing before? What is the problem? Why did it happen?effect had? What action is going to be taken? What are our work processes to prevent recurrence of non-conforming work?
If ineffective
begin the corrective action cycle again
preventative action
change implemented to address a weakness in a system that is not yet responsible for causing non- conforming work