Adverse Occurrence Root Cause Analysis - Essay Example

Adverse Occurrence Root Cause Analysis Adverse Occurrence Root Cause Analysis Root cause analysis (RCA) is a set of problem solving methods designed to identify the root causes of problems, aiming to address, correct and eliminate them, rather than merely handling the obvious symptoms (Andersen & Fagerhaug, 2006). This prevents future recurrence, as well. This paper will discuss the RCA process that Mary Bridge Childrens Hospital can use to perform RCA on the wrong diagnosis they received. The RCA process selected is REASON.

This system software gives guidelines to expose the root causes of operations problems, enabling their management and tracking corrective action plans. At the same time, it communicates the lessons learned from the problem solving activities (Decision Systems, 2012). REASON integrates the need to perform RCA on both sentinel events and the routine analysis of everyday counter-quality problems for ongoing activities. This cuts down on the amount of time needed for scheduling, required number of personnel as well as training (Decision Systems, 2012).

It does this by providing a scalable process that matches the analysis time and effort to the weight of the crisis. They are summarized as REASON FrontLine for small issues, REASON Express for significant issues, and REASON Pro for serious and sentinel event issues (Decision Systems, 2012). These steps are simplified further by a wizard that asks the attendant to name the problem, the causes, and a business process that will rectify it.  The process would work in five stages as below:Problem definition This will focus on describing what is seen happening.

It will lay down the symptoms observed in the patient. The problem is defined factually including the qualitative and quantitative properties of the dangerous outcomes. It additionally includes detailing the nature, the degree, the locations, and the timings of the occurrence.Collection of data This stage will avail proof of existence of the problem. It will also specify the period the problem has existed up to the final crisis, including the impact it has had on the patient. For each behavior, situation, action, or inaction it will be specified what should have been and how it differs from the actual one observed (Andersen & Fagerhaug, 2006).

The best suited tool here is the CATWOE. It involves using different perspectives to view the same situation. In it are the customers (patients), the actors who implement the solutions, the transformation process which is affected, and the world’s view, the owner of the process and finally environmental limitations (Hardy, 2010).Identifying possible factors causing the problem This stage examines the sequence of events that led to the problem, and conditions that allowed them to occur. It seeks to uncover if there are other smaller problems linked to the occurrence of the main one.

This stage should also identify as many factors as possible. The 5-whys tool will also come into play here, seeking to identify the causes associated with every step in the sequence towards the defined problem and event (Hardy, 2010). The question ‘why’ will be asked as many times as possible until the factors that directly resulted in the problem are reached. The problem will then be broken down into smaller, detailed parts for a better understanding of the larger picture. All the possible factors will be charted using the cause and effect diagrams to see where the problem began (Andersen & Fagerhaug, 2006).

Identifying the cause This stage will use the same tools used to identify the factors causing the problem to give reasons as to why they exist, and the actual reason the problem occurred. They are classified into factors relating to an event in the sequence and root causes. The tools are designed to dig deeper at all levels of cause and effect (Hardy, 2010).Recommending and Implementing Solutions Here, recommendations for what can be done and how they are to be implemented to prevent a repeat of the problem are given.

The risks involved are also spelt out. The cause-and-effect process is analyzed to identify the needed changes for different systems and plan ahead to foresee the effects of the solution and possible failures (Andersen & Fagerhaug, 2006). A valuable tool here is Failure Mode and Effects Analysis. It reduces the need of repeated, future RCAs..ReferencesAndersen, B., & Fagerhaug, T. (2006). Root cause analysis: Simplified tools and techniques. Milwaukee: Quality Press.Decision Systems, (2012). REASON Root cause analysis software.

Retrieved from http://www.rootcause.com/products/software/reason-rca.htmlHardy, T. L. (2010). The system safety skeptic: Lessons learned in safety management and engineering. Bloomington: Author House.