Root Cause Analysis — A Mock Case Study

Abstract

AbstractA percentage of Radiation Therapy treatments will result in an error, be it a treatment or planning error. These errors, or incidents, will range from the very insignificant to the very significant. Although some incidents may be able to be corrected in future treatments, in general it is not possible to completely correct an incorrect treatment. The one positive that can be taken from every incident is to learn from it, identifying the processes which failed and replacing these with more robust processes.A root cause analysis (RCA) is a tool which focuses investigation of an incident onto processes and away from people. Incident analysis will only ever be successful if personal blame is removed.This paper uses a mock case study to take the reader through the process of an RCA with the purpose of raising the appreciation of the value and benefits of such an analysis.