Application Of Root Cause Analysis Research Articles

Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report

BackgroundAn intravesical gas explosion is a rare complication of transurethral resection of the prostate (TURP). It was first reported in English literature in 1926, and up to 2022 were only forty-one cases. Injury from an intravesical gas explosion, in the most severe cases appearing as extraperitoneal or intraperitoneal bladder rupture needed emergent repair surgery.Case presentationWe present a case of a 75-year-old man who suffered an intravesical gas explosion during TURP. The patient underwent an emergent exploratory laparotomy for bladder repair and was transferred to the intensive care unit for further observation and treatment. Under the medical team’s care for up to sixty days, the patient recovered smoothly without clinical sequelae.ConclusionsThis case report presents an example of a rare complication of intravesical gas explosion during TURP, utilizing root cause analysis (RCA) to comprehend causal relationships and team strategies and tools to improve performance and patient safety (TeamSTEPPS) method delivers four teamwork skills that can be utilized during surgery and five recommendations to avoid gas explosions during TURP to prevent the recurrence of medical errors. In modern healthcare systems, promoting patient safety is crucial. Once complications appear, RCA and TeamSTEPPS are helpful means to support the healthcare team reflect and improve as a team.

Fishbone diagram: Application of root cause analysis in internal audit planning

Purpose: This study applies a fishbone diagram to analyze the root cause of problems in the internal audit planning of J Corp, an Indonesian state-owned enterprise. Research methodology: A qualitative approach was employed to conduct a case study at the internal audit unit of an Indonesian state-owned enterprise. Research data were gathered from the results of focus group discussions with internal auditors, the analysis of the company’s standard operating procedure for internal auditing, and the observation of the workflow of internal audit planning. These data were then analyzed to identify the root causes of these problems. Results: Six key factors were identified that cause poor internal audit planning at J Corp. These are policies, processes, people, plants, programs, and products. To overcome these problems, this study provides several suggestions that can be implemented in the internal audit unit of J Corp. Limitations: This study is limited by the nature of the business and environment of J Corp, which affected the problems arising in the process of its internal audit planning; hence, the need to understand the entity to replicate this method for future research. Contribution: This study could be directly beneficial for internal auditors at J Corp to immediately improve the business process of internal audit planning. Furthermore, this study could contribute to future studies in which researchers or practitioners could replicate this method in another context. Novelty: The fishbone diagram was used to analyze the root causes of problems in the process of internal audit planning. Studies on the improvement of internal audit planning have been limited.

Root cause analysis of safety incidents in antineoplastic use in children.

to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients. a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors. in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages. the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

Root-Cause Problem Solving in an Industry 4.0 Context

Root cause analysis (RCA) is a highly effective methodology for product design teams and manufacturing managers to engage in creative problem solving by utilizing the tools of the Fourth Industrial Revolution—Industry 4.0. This article outlines the RCA problem-solving process as it is applied to detect and resolve problems in a consumer product manufacturing setting. This article presents a case study of collaborative design, testing, and implementation of a product-specific solution to resolve quality control issues caused by a flawed component specification. The provided case study details company's application of RCA. Once the problem is identified, we describe how the design and production teams collaborated to verify and validate the revised product design via three-dimensional product simulations. Having identified a solution, the company's manufacturing managers and supervisory staff incorporate this change into their standard operating procedures, conduct staff training, and share the solution across the organization. This problem-solving approach, implemented as part of a wider continuous improvement effort, also includes the utilization of digital applications and smart devices to share data across the company in real time.

Waste management by application of quality control tools in the manufacturing industry – a case study

Waste management (WM) is a multi-disciplinary activity involving engineering principles, economics, urban and regional planning, management techniques and social sciences, to minimise the different types of wastes in the processes in the manufacturing industry. This study attempts to improve the performance of magnetic particle inspection machines, remove fire hazardous and reduce the use of kerosene oil using application of root cause analysis through quality control tools in manufacturing Industry. With implementation of tools modified action resources are improved which leads to continuous improvement in productivity and product quality in the organisation.

Application of root cause analysis to increase material removal rate for productivity improvement: A case study of the press manufacturing industry

The bore machining of a large size cylindrical job on a lathe machine is a challenging job. Due to the large diameter of job or financial constraints, it is not always possible to use the steady rest. This results in the overhang of a job, which directly affects the material removal rate. This paper discusses the use of lean manufacturing in a press manufacturing industry to improve productivity through increased material removal rate of boring operation. A flange fixture is developed and it has reduced the machining time by 9.5 h.

Waste management by application of quality control tools in the manufacturing industry – a case study

Waste management (WM) is a multi-disciplinary activity involving engineering principles, economics, urban and regional planning, management techniques and social sciences, to minimise the different types of wastes in the processes in the manufacturing industry. This study attempts to improve the performance of magnetic particle inspection machines, remove fire hazardous and reduce the use of kerosene oil using application of root cause analysis through quality control tools in manufacturing Industry. With implementation of tools modified action resources are improved which leads to continuous improvement in productivity and product quality in the organisation.

Application of root cause analysis in reducing the error rate of pathology specimens of patients with surgery

目的 根因分析法应用在手术患者病理标本送检中的护理效果及临床应用价值。 方法 回顾性分析2016年1月至2017年12月临海市中医院手术治疗并需要进行病理标本送检的患者220例的临床资料，按照标本送检管理模式不同分为观察组和对照组，每组110例。对照组采取常规方式进行病理标本送检，观察组采取根因分析法开展病理标本送检，比较两组病理标本申请单填写正确、病理标本标签填写准确情况、送检所需时间、标本滞存率以及送检差错率情况。 结果 观察组病理标本申请单填写正确率为100.00%，病理标本标签填写正确率99.09%；对照组病理标本申请单填写正确率为74.55%，病理标本标签填写正确率72.73%，均差异有统计学意义(χ2＝5.278、5.189，均P<0.05)。观察组病理标本送检所需时间为(26.76±1.64)min，标本滞存率为11.82%，送检差错率为0.91%；对照组病理标本送检所需时间为(47.49±2.56)min，标本滞存率为52.73%，送检差错率为7.27%，均差异有统计学意义(t＝9.328，χ2＝4.932、5.189，均P<0.05)。 结论 根因分析法应用在手术患者病理标本送检中可以提升病理标本文书制作质量，缩短标本送检时间，降低标本滞存和送检差错事件发生，值得在临床推广应用。

The application of root cause analysis in psychiatry department

Objective To check out the function of root cause analysis(RCA)in reducing workplace violence in psychiatric department. Methods An RCA team was set up to analyze the proximate cause and the ultimate cause of workplace violence by using the method of RCA, and then the improved measures were proposed and carried out. Results Before using the method of RCA, 69 nurses suffered workplace violence.After using RCA, 59 nurses suffered workplace violence.The abilities of nurses have been improved. Conclusions RCA is a scientific method in the management of workplace violence in psychiatric department.RCA method can improve the comprehensive ability of nurses. Key words: Root cause analysis; Psychiatric; Workplace violence

Root cause analysis in quality problem solving of research information systems: a case study

Nowadays the information systems have become a key part of any organisation. On the one hand these systems are considered as basis of management decisions and on the other hand they serve the within or outside of organisation's users and clients as well. Therefore good performances of these systems could become one of the main objectives of senior managers in any organisation. Research information systems (RIS) are not exceptional on these norms either and in order to continually improve these systems their quality aspects should be analysed and improved to achieve better performances. In this paper, application of root cause analysis in RIS using a case study for solving quality problems is considered. This approach is used in three main stages of RIS means data entry, indexing and dissemination of information. Results of this paper show that through application of root cause analysis identifying, categorising and defining appropriate corrective action for quality problems of RIS could be easily achieved. Furthermore, main results of application of this approach are presented.

Implementing root cause analysis in Iranian hospitals: challenges and benefits.

Root cause analysis (RCA) has been widely used for retrospective investigations of patient safety incidents. To increase patient safety competencies, RCA has recently been introduced in Iranian hospitals. The aims of the current study were to explore team members' experiences and perceptions of RCA and to identify the challenges and benefits of using it in Iranian hospitals from their perspective. A qualitative study was conducted consisting of 32 semi-structured interviews with health professionals who participated in the national training programme and were involved in RCA investigations. Data were analysed using the thematic analysis method. The participants encountered a range of obstacles while conducting RCA, including time constraints, a lack of resources, the blame culture and unsupportive colleagues. They stressed the need for further leadership support and cultural change within the Iranian healthcare system to facilitate the application of RCA. RCA was perceived as a beneficial analytical tool that improved patient care, fostered teamwork and communication among staff and promoted safety culture. This study concluded that applying RCA in the Iranian healthcare setting has had a significant impact on improving commitment to safety. However, the general adoption of this method is hindered by the lack of workplace and system supports. To maximize profits from RCA, clinical leaders must assign a high priority to RCA investigations and support RCA team efforts. Copyright © 2016 John Wiley & Sons, Ltd.

Application of root cause analysis on the Swiss cheese model in the psychiatric nursing adverse events

Objective To study the clinical methods and effects of root cause analysis on the application of the Swiss cheese model in the psychiatric nursing adverse events. Methods Safety management groups were established to train nurses, use Swiss cheese model to analysis the root cause, formulate the corrective measures. The annual rates of incidence and reporting rate of adverse events were compared. Results One year after the root cause analysis on the application of the Swiss cheese model, the annual number of patients increased from 3 420 to 3 730, the cases of nursing adverse events reduced from 141 to 120, and the rate of nursing adverse events dropped from 4.12 percents to 3.21 percents (χ2=4.16, P<0.05). The reporting cases of nursing adverse events increased from 65 to 102, and the reporting rate of nursing adverse events enhanced from 46.10 percents to 85.00 percents (χ2=42.57, P<0.01). Conclusions The use of root cause analysis on the application of the Swiss cheese model is the effective management model to analyze the nursing adverse events and to improve the nursing safety. Key words: Swiss cheese model; Root cause analyses; Adverse event

Root cause analysis in infusion nursing: applying quality improvement tools for adverse events.

The application of root cause analysis (RCA) to health care began in the Veteran's Administration system and spread to Joint Commission-accredited organizations when it became a requirement for accreditation. The success of this valuable quality improvement tool relies on understanding the principles of patient safety, assembling a team, and producing and completing action items aimed at correcting root causes of adverse events. This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection.

Application of root cause analysis in falling of hospitalized elderly patients

Objective To analyze the falling events using root cause analysis (RCA) in hospitalized elderly patients in order to supply theoretic reference for precaution of falling events. Methods RCA method was used to analyze the root cause against 62 cases of nursing adverse events of hospitalized elderly patients' falling. Results Hospitalized elderly patients' falling is related to various factors such as body, disease, medicine, psychology, environment and so on. The root cause lied in the elderly' physical function decline, risk factors of external environment, unfulfilled health education, and lack of the care and support system for the elderly, among which cerebral infarction belonging to the disease factors accounted for 22.58% (14/62), which was the highest; next was senile dementia [20.97% (13/62)]. The rates of agents against psychiatric disorders belonging to the medicine factors and no braking of bed pulley and no use of blister light belonging to environmental factors were the lowest, all were 3.23% (2/62). Conclusions The falling reason of elderly inpatients can be found out by RCA in order to attain the purpose of improving procedure and prevention in advance. Key words: Inpatients; Aged; Accidental falls; Root cause analysis

Application of root cause analysis in the management of pediatric transfusion adverse events

Objective To investigate the application of root cause analysis (RCA) in the management of pediatric transfusion adverse events,in order to reduce the occurrence rate of adverse events in pediatric transfusion.Methods Root cause analysis method was used from October 2011 to March 2012.Occurrence rate of adverse events,double check and accuracy of transfusion were compared before and after the implementation of RCA.Results Six months before RCA,the occurrence rate of adverse events was 0.32％ and six months after RCA was 0.03％,and the difference was statistically significant (x2 =19.146,P ＜ 0.01).The rate of double check and accuracy of transfusion were respectively 100％ and 98％ after RCA,which were higher than those before RCA (74％ and 83％),and the differences were statistically significant (x2 =29.885,13.085,respectively; P ＜ 0.01).Conclusions Root cause analysis can effectively control related factors during pediatric transfusion,reduce the occurrence rate of adverse events and improve transfusion safety. Key words: Hospital, pediatrics; Safety management; Root cause analysis; Transfusion adverse events

Use of Root Cause Analysis to Prevent Falls and Promote Patient Safety in Clinical Rehabilitation

Objective: To apply Root Cause Analysis to explore the causes of patient falls and determine the implement procedures to prevent them. Design: Root Cause Analysis was conducted retrospectively using comprehensive error review to discover and correct the causes of errors. Setting: Physical medicine and rehabilitation department in a medical center in Taiwan. Interventions: We used causal trees to clarify possible reasons for patient falls, including the patients’ personal characteristics, factors pertaining to the interactions among the medical team, the team’s workload and level of training, and the quality of communication between medical staff and the patient. In advance, Root Cause Analysis was analyzed by using reactive barriers for each factor. Main outcome measures: Incidence and complications of patient falls before and after Root Cause Analysis. Results: No patient falls occurred during the first 6 months after implementing the measures identified in the analysis. Two falls occurred after 6 months, but the patients were both assisted promptly and suffered no injuries. The annual incidence of falls decreased from 4.8 per 100,000 subjects to 1.9 and 0.9 in the next two years of follow up, respectively. Conclusion: The application of root cause analysis in the setting of clinical rehabilitation did not completely prevent falls. However, the incidence and complication of falls were reduced. Therefore, it is worthwhile to promote application of Root Cause Analysis to clinical rehabilitation treatment to enhance the quality of patient safety in the future.

Using Root Cause Analysis for Evaluating Program Improvement

A common evaluation purpose is to determine whether a policy or program was implemented as intended: referred to as formative evaluation, process evaluation, or evaluating program improvement. A well-designed formative evaluation is important in: detecting program drift; providing timely feedback to program staff to make cost-saving mid-course corrections; reassuring the sponsor that quality assurance measures are implemented to protect investments; and interpreting impact/outcome evaluation. A formative evaluation should not just gather data on deviations from an anticipated course of action, but provide recommendations for improvement. Current methods for program improvement vary in their ability to solicit targeted recommendations. Root cause analysis (RCA) is a well-established, robust methodology used in a variety of disciplines. RCA has been primarily used by evaluators operating from a theory-driven orientation to evaluate the merit and worth of a program or policy. Surprisingly, a review of the literature suggests that RCA's utility as a program improvement tool has remained largely unrecognised in evaluation. This article illustrates the application of RCA in evaluating program improvement. The conditions under which RCA might be preferred over other formative evaluation methods are discussed.

Root cause analysis of an old accident in an explosives production plant

Twenty-six years ago, a massive accident occurred in the Semtin explosives plant in Czechoslovakia. The results of investigations which were carried out (but kept confidential at the time) were made available after 1989, but have not been published in a summarized form to date. Reopening of the results of old investigations and application of root cause analysis deepens our understanding of accident causes and leads to the conclusion that, according to today’s standards, the analysis was not completed at the time of the accident and therefore neither some of the practical aspects of the event nor the social, professional, and political climate it should have exposed have ever been fully understood. New analysis shows that plant safety management had decayed. The results demonstrate as well how substantial a shift has occurred in the understanding of causes and in performing and organizing their analyses during the elapsed quarter-century. The new examination employs a few innovations of root cause analysis. A tight connection between the analysis and the assumptions about the structure of safety management of investigated processes will be underlined. Suitable illustration will be proposed. Detail requirements on the form and content of a root cause map will be specified. Finally it is shown that even the root cause analysis has its limitations and that it may not be sufficient to finish the investigation of causes satisfactorily. This motivates for the identification of levels of causes which underlie the root causes.

Application of root cause analysis on malpractice claim files related to diagnostic failures

BackgroundLarge numbers of claim files present a potentially valuable source of information to get insight on possibilities for prevention of claims. Therefore, the feasibility of root cause analyses on incidents...

Application of root cause analysis in improvement of product quality and productivity

Root-cause identification for quality and productivity related problems are key issues for manufacturing processes. It has been a very challenging engineering problem particularly in a multistage manufacturing, where maximum number of processes and activities are performed. However, it may also be implemented with ease in each and every individual set up and activities in any manufacturing process. In this paper, root-cause identification methodology has been adopted to eliminate the dimensional defects in cutting operation in CNC oxy flame cutting machine and a rejection has been reduced from 11.87% to 1.92% on an average. A detailed experimental study has illustrated the effectiveness of the proposed methodology.