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