Root-cause Analysis Research Articles

Six dilemmas for stakeholders inherently affecting data sharing during a zoonotic (re-)emerging infectious disease outbreak response

BackgroundTimely access to outbreak related data, particularly in the early events of a spillover, is important to support evidence based control measures in response to outbreaks of zoonotic Emerging Infectious Diseases (EID). Yet, this is impeded by several barriers that need to be understood to promote timely sharing of data. Using the MERS epidemic as a model for a zoonotic EID outbreak, this study sought to provide an in-depth understanding of data sharing practices.MethodsSemi-structured interviews with 25 experts were conducted, along with Focus Group Discussions with 15 additional experts. A root-cause analysis was performed to examine the causal relationships between barriers. Enablers were mapped to the root-cause analysis to understand their influence on the barriers. Finally, root causes were placed in context of core dilemmas identified from the qualitative analysis.FindingsEight barriers to data sharing were identified, related to collaboration, technical preparedness, regulations, and (conflict of) interests, and placed in the context of six dilemmas inherent to the multi-stakeholder collaboration required for a zoonotic outbreak response. Fourteen identified enablers showed the willingness of stakeholders to overcome or circumvent these barriers, but also indicated the inherent trial and error nature of implementing such enablers.InterpretationAddressing the barriers requires solutions that must consider the complexity and interconnectedness of the root causes underlying them, and should consider the distinct scopes and interests of the different stakeholders. Insights provided by this study can be used to encourage data sharing practices for future outbreaksFundingWellcome Trust and UK Aid; EU-H2020 Societal Challenges (grant agreement no. 643476), Nederlandse Organisatie voor Wetenschappelijk Onderzoek (VI.Veni.201S.044)

Post-colonoscopy colorectal cancers in a national fecal immunochemical test-based colorectal cancer screening program.

Post-colonoscopy colorectal cancers (PCCRCs) decrease the effect of colorectal cancer (CRC) screening programs. To enable PCCRC incidence reduction in the long-term, we classified PCCRCs diagnosed after colonoscopies performed in a fecal immunochemical test (FIT)-based screening program. PCCRCs diagnosed after colonoscopies performed between 2014-2016 for a positive FIT in the Dutch CRC screening program were included. PCCRCs were categorized according to the World Endoscopy Organization consensus statement into (a) interval PCCRC (diagnosed before the recommended surveillance); (b) non-interval type A (diagnosed at the recommended surveillance interval); (c) non-interval type B (diagnosed after the recommended surveillance interval); or (d) non-interval type C (diagnosed after the intended recommended surveillance interval, with surveillance not implemented owing to co-morbidity). The most probable etiology was determined by root-cause analysis. Tumor stage distributions were compared between categories. 116362 colonoscopies were performed after a positive FIT with 9978 screen-detected CRCs. During follow-up, 432 PCCRCs were diagnosed. The 3-year PCCRC rate was 2.7%. PCCRCs were categorized as interval (53.5%), non-interval type A (14.6%), non-interval type B (30.6%), and non-interval type C (1.4%). The most common etiology for interval PCCRCs was possible missed lesion with adequate examination (73.6%); they were more often diagnosed at an advanced stage (stage III/IV; 53.2%) compared with non-interval type A (15.9%; P<0.001) and non-interval type B (40.9%; P=0.03) PCCRCs. The 3-year PCCRC rate was low in this FIT-based CRC screening program. Approximately half of PCCRCs were interval PCCRCs. These were mostly caused by missed lesions and were diagnosed at a more advanced stage. This emphasizes the importance of high quality colonoscopy with optimal polyp detection.

Root Cause Analysis: Unraveling Common Laboratory Challenges.

Diverse errors occur in a pathology laboratory and manual mistakes are the most common. There are various advancements to replace manual procedures with digitized automation techniques. Guidelines and protocols are available to run a standard pathology laboratory. But, even with such attempts to reinforce and strengthen the protocols, the complete elimination of errors is yet not possible. Root cause analysis (RCA) is the best way forward to develop an error-free laboratory, In this review, the importance of RCA, common errors taking place in laboratories, methods to carry out RCA, and its effectiveness are discussed in detail. The review also highlights the potential of RCA to provide long-term quality improvement and efficient laboratory management.

Factors Associated With Nasogastric Tube Placement-Related Complications in a Single Academic Medical Center.

At our 710-bed academic medical center, nine (9) patients sustained injuries during nasogastric (NG) tube insertion attempts over a 16-month period (March 2021-July 2022). No injuries were reported during the comparable period before these events. This increase in reported events prompted an in-depth analysis to determine the root causes and implement a process improvement plan. Root cause analysis (RCA) of these events failed to identify risk factors or actionable themes. The RCAs demonstrated wide variation in the number of insertion attempts and techniques. A standard process was created to provide team members with guidance for escalation when NG tube placement was difficult. Although the complication rate for NG tube insertion was comparable with the criterion standard for large tertiary care institutions, we focused on minimizing risk and improving outcomes by creating a standard process for NG tube placement.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis.

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted. Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

Analisis Pengendalian Kualitas Produksi Kaleng PT XYZ dengan Menggunakan Metode RCA (Root Cause Analysis)

PT XYZ was established as a company engaged in packaging manufacturing, especially biscuit cans and paint cans. PT XYZ was established in 1977 and has grown to become one of the leading manufacturing companies in Indonesia. In the production process, there are often many rejected goods which causes a lot of waste to occur and a decrease in profits due to the large number of rejected products at PT XYZ. Therefore, it is necessary to carry out quality control to find out the meeting point that causes problems to occur every period. In the quality control process using RCA (Root Cause Analysis). From the results of quality control, it was found that the dominant cause of the large number of rejected goods that occurred, namely the type of rupture reject which had a percentage of 98%, so that there was a need for improvement in the production process of the PT XYZ company that occurred which caused the product to reject.

Unplanned Sarcoma Excisions: Understanding How They Happen.

Soft-tissue sarcomas present as a mass with nonspecific symptoms, and unplanned excisions commonly occur. The purpose of this study was to analyze the incidence of unplanned excisions performed by orthopaedic surgeons and to conduct a root cause analysis (RCA) of the steps that led to unplanned excisions in all the cases. A retrospective case-control study was conducted. Two cohorts were identified, one including patients who underwent an unplanned excision of a soft-tissue sarcoma (n = 107) and a second cohort with patients whose entire care was performed at our sarcoma center (n = 102). A RCA was conducted with the whole sample to identify the preventable causes that led to sarcoma unplanned excisions. Orthopedic surgeons were the second group of physicians to perform the most unplanned excisions, only behind general surgeons. Inadequate imaging was encountered in 76.6% of the patients (n = 82, 95% confidence interval, 67.8 to 83.6). Forty-five patients (42.1%) had no imaging studies before the unplanned procedure. In the RCA, the most notable obstacles found were (1) incorrect assumption of a benign diagnosis, (2) failure to obtain the appropriate imaging study, (3) incorrectly reported imaging studies, (4) failure to order a biopsy, and (5) incorrect reporting of the biopsy. Despite educational efforts, unplanned excisions and the devastating consequences that sometimes follow continue to occur. Orthopaedic surgeons persist in playing a role in the unplanned procedure burden.

Analysis of Material Unavailability in the Beside Table Production Process Using Root Cause Analysis (RCA) and 5SMethods in A Furniture Company

Furniture manufacturing company, producing products such as tenban, beside cabinet, beside table. In carrying out its production, furniture companies often occur conditions of material unavailability when the production process is in progress and there is a difference between the amount of material inventory stock in the information system (computer) and the stock of materials in the warehouse. This research will identify the factors that cause material unavailability during production using the Root cause analysis (RCA) method. Several factors causematerial unavailability, namely, errors in inputting material stock data, not doing physical stock-taking regularly, material moving to other parts of the shelf, material storage is not neat because there are few storage shelves and material identity labels are not yet valid, recording stock-taking is still manual, material or spare parts are lost, return material (defects) from users is placed on the same shelf as OK material and narrow warehouse space and limited storage shelves. To overcome these problems, this research provides a sustainable improvement proposal by implementing the lean thinking concept with the 5S principle in the company. It is expected that with the application of the 5S concept in this company so that the material inventory system in the warehouse is controlled optimally so that it can increase the productivity of employee performance in the company and a better change for the company.

Root Cause Analysis for Incident Reporting Cases of Radiological Technologists Based on Years of Experience

Root Cause Analysis (RCA) of reported incident reports can lead to measures to prevent the recurrence of accidents. The purpose of this study is to clarify the relationship between the occurrence of cases, causal factors, contributing factors, and the experience years of the reporters classified into three groups: less than 2 years, 3 to less than 5 years, and more than 5 years, for incident reports subject to RCA. From April 2018 to March 2023, a chi-square test was conducted between each item extracted from 239 cases subject to RCA and the experience years of the reporters, with a significance level of less than 5% considered significant. Regarding the occurrence cases, radiological technologists with longer experience had more misidentified a patient and fewer errors in imaging conditions and range, while radiological technologists with 3 to less than 5 years of experience had more errors in imaging conditions (p<0.001). In terms of occurrence factors, radiological technologists with 3 to less than 5 years of experience had more cases of insufficient confirmation (p<0.05). For contributing factors, there was no significant difference between the experience year groups (p=0.19), with "Impatience" being the most common factor. This survey suggested that in incident reports of radiological technologists, "Impatience" is a contributing factor that can occur regardless of years of experience.

ОГЛЯД МЕХАНІЗМІВ ROOT CAUSE АНАЛІЗУ ТЕЛЕКОМУНІКАЦІЙНИХ МЕРЕЖ

Telecommunication networks are an integral part of modern information society, providing data transmission and communication among millions of users worldwide. The complexity and scale of these networks are constantly growing, which increases the demands on their reliability and stability. One of the key tasks in ensuring the efficient operation of telecommunication networks is the identification and elimination of the root causes of failures and anomalies that can significantly affect the quality of service for end users. Root cause analysis (RCA) is a powerful tool for identifying the primary causes of problems, preventing their recurrence, and enhancing the overall reliability of networks. The article provides a detailed review of contemporary methods and tools of RCA used in telecommunication networks. In particular, methods such as fishbone diagram analysis, the «five whys» method, fault tree analysis, and the application of machine learning for big data analysis are considered. Each of these approaches has its advantages and disadvantages, and their comprehensive use allows for higher accuracy and efficiency in identifying the root causes of problems. Practical examples demonstrate the effectiveness of applying various RCA methods to solve specific problems in telecommunication networks. For instance, the use of fishbone diagram analysis and the «five whys» method allows for the identification of the primary causes of network delays and equipment issues at base stations. The implementation of failure prediction systems based on machine learning significantly enhances network reliability by allowing for the early detection of potential problems and the necessary technical measures. The prospects for the development of RCA in telecommunication networks are outlined. The primary focus is on the development of adaptive and self-learning systems capable of dynamically responding to changing network conditions. The use of more complex artificial intelligence algorithms and tools for predicting potential problems will significantly improve the effectiveness of RCA and ensure high-quality telecommunication services.

Application of Multidimensional Quality Management Tools in the Management of Medical Adverse Events.

This study aims to investigate the impact of multidimensional quality management tools in establishing a medical adverse event management system, with the aim of continuously improving medical quality and safety while ensuring patient well-being. This study introduces risk management theories, such as the "Gray Rhino Theory", and employs quality management tools like the Plan-Do-Check-Act (PDCA) cycle, Quality Control Circle (QCC), and Root Cause Analysis (RCA), to provide relevant quality management education and training to employees. This approach facilitates the establishment of a medical adverse event management system that encourages reporting and fosters a blame-free reporting culture, while simultaneously implementing quality management across the entire process. The regular utilization of the QCC facilitates ongoing quality improvement. Furthermore, for sentinel events and patient harm incidents with educational values, the study employs the Incident Decision Tree (IDT) to determine appropriate actions. Additionally, the hospital initiates RCA for system-wide improvements, focusing on areas such as management, institutional processes, and environmental aspects. Moreover, an internal medical quality improvement case competition is organized, with outstanding cases being selected to participate in the multidimensional quality management competition organized by the National Quality Management Alliance. The study reveals a significant improvement in employees' awareness of adverse events, the percentage of employees reporting adverse events increased significantly from 39.15% in 2019 to 49.77% in 2022, P=0.002. Furthermore, the adverse event reporting rate has risen significantly from 2.78% (2019) to 5.96% (2022), P=0.002. Additionally, each department has been able to utilize QCC or RCA tools for quality improvement, thereby further reinforcing the development of a patient safety culture. Multidimensional quality management tools play a crucial role in establishing a hospital's adverse event management system, promoting continuous improvement in medical quality, ensuring patient safety, and effectively implementing a culture of patient safety.

On the Use of Spatial Graphs for Performance Degradation Root-Cause Analysis Toward Self-Healing Mobile Networks

On the Use of Spatial Graphs for Performance Degradation Root-Cause Analysis Toward Self-Healing Mobile Networks

Problem-solving practices in the automotive industry: an initial framework

This paper aims to contribute to both theory and practice by describing current problem-solving practices, proposed by various authors, as part of the quality management process of companies in the automotive industry. The paper, based on proposals from different authors, also includes a set of quality tools that can be used in the different steps of the problem-solving process. The results show that there is general agreement on best problem-solving practices, emphasizing root-cause analysis and the development and implementation of corrective actions, which are included in all the proposals analyzed. The analysis also shows that many quality tools can be used in the different steps of this process. In addition, the paper proposes an initial framework developed by the authors that can be used by organizations to improve their problem-solving practices.

PRIORITY STRATEGIES TO CREATE AN ENVIRONMENTALLY FRIENDLY BATIK IN TRUSMI VILLAGE

Trusmi village is very famous for batik production, which is manufactured by industrial and small and medium enterprises (SMEs) at various scales. Batik artisans in Trusmi still practice traditional batik technique, which have been passed down from generation to generation for decades. Materials such as mori cloth, wax, and textile dyes, are readily available and sold in Trusmi village. Environmental and health impacts can arise from the production process of stamped and printed batik fabric, which involves the use of many chemicals and exposure to heat in the working environment. The use of chemical dyes in the fabric dyeing process, where craftsmen manually perform the coloring, does not adhere to safety and health. Furthermore, the remaining dye waste is disposed of into the environment without undergoing proper processing. The research aims to address the issue of batik production process waste in Trusmi village, Cirebon, West Java Province, using the root cause analysis (RCA) method. The article presents a root cause analysis of environmental impacts using RCA and provides advice on minimizing environmental effects at the most optimal cost. Based on the result of the research using the RCA method, the most critical strategy identified for achieving environmentally friendly batik production, as determined by the Analytical Hierarchy Process (AHP) and Analytical Network Process (ANP) analysis is to increase the awareness of batik producers.

Root Cause Analysis Of Quality Control And Cost Control Of Implementing The Referback Program In First Level Health Facilities

Background: The incidence of chronic diseases in Jambi City is still high from year to year. The Referback Program (PRB) is one of the government's efforts through BPJS Health in collaboration with health facilities to ensure chronic disease sufferers have easier access to obtain the medicines they need at an efficient cost. This research aims to analyze the main problems of quality control and cost control of PRB implementation in terms of man, material-machine, method, market, money and time elements at FKTP in Jambi City. Methods: The research was conducted using qualitative methods using the perspective of Root Cause Analysis (RCA) theory to form research procedures. The informants consisted of the person in charge of PRB, the head of the community health center and PRB participants at FKTP in Jambi City. The research instrument is a structured interview sheet. Data analysis uses thematic analysis techniques according to the RCA flow Results: The research results found that the main cause of the problem was weak coordination between PRB officers and BPJS Health in implementing PRB at FKTP. Conclusion: It is recommended that BPJS Health be more active in providing outreach and special training to PRB officers as well as setting up a clear monitoring and evaluation system regarding the implementation of PRB in FKTP

Reduced painting defects in the 4-wheeled vehicle industry on product type H-1 using the lean six sigma-DMAIC approach

The current era provides challenges for several automotive industries to be able to compete and maintain the quality of their products. For four-wheeled auto­motive companies, satisfying customers regarding the visual appear­ance of the vehicle body is very important. However, internally, automotive companies still found many defects or failures in painting, amounting to 32.6%. Apart from that, rework also results in additional costs that the company must incur during the painting process. This study aims to clarify types of painting defects, analyze root causes, provide solutions, improve process capabilities, and in­crease the sigma level in the painting process in the four-wheeled vehicle industry. This study uses the Lean Six Sigma method, which is integrated into the DMAIC approach and other improve­ment tools. As a result, this study clarifies four critical defects in the orange peel defects of the painting section, craters, melting, and blur. This study has resulted in several corrective action solutions, including tightening supervision of the performance of painting section operators so that they are consistent and committed to working according to the Standard Operational Procedure (SOP) or work instructions that have been created. A competency matrix is used to evaluate operator performance, which is reported to super­iors and subordinates by the supervisory depart­ment. After carrying out corrective action, this study increased the process capability from 1.17 to 1.92. The higher the capability value, the higher the sigma level. This study also has increased the sigma level from 2.76 to 3.42, meaning an increase of 78%.&#x0D; .

Implementation of Objective Matrix and Root Cause Analysis for Productivity Analysis PT. Indomarco Adi Prima SP Deket Lamongan

PT Indomarco Adi Prima Stock Point Deket Lamongan is one of the business units of PT Indofood Sukses Makmur Tbk, which distributes consumer products. The company has 300 outlets in grocery stores and modern stores with a distribution target of 30 outlets for each salesman in a day. However, in its implementation, the target is only sometimes achieved. Other problems, such as product delivery errors and delivery delays, occur frequently. This research aims to analyze the company's productivity level using the Objective Matrix (OMAX) method. Productivity measurement also involves the Analytical Hierarchy Process (AHP) method in determining the weight of each ratio. Based on the calculation of productivity during the measurement period from January 2022 to December 2022 using Objective Matrix (OMAX), the results obtained are productivity index values that decreased during the measurement period, namely February (-4,75%), March (-3.90%), May (-17.48%), June (-11.92%), July (-31.28%), and October (-7.04%). Then, based on the results of productivity indicator analysis, it is known which ratio indicator has the lowest value and causes the productivity index to fall, namely ratio 1, ratio 2, ratio 5, ratio 6, and ratio 7. The decrease in productivity index based on Root Cause Analysis (RCA) using fishbone diagram tools due to no heat reducer, no computer and truck maintenance schedule, less communication between employees, travel time estimation is not good, attendance system updates are not carried out, limited warehouse area, high work intensity, no instructions for the preparation of goods in the warehouse area, stock goods arrive late, rainy season, road repairs, no periodic checks, and unpredictable road conditions.

Targeted solutions to increase dolutegravir coverage, viral load testing coverage, and viral suppression among children living with HIV in Togo: An analysis of routine facility data.

According to UNAIDS, Togo halved AIDS-related deaths among children ages 0-14 from 2010 to 2020. However, available data show low dolutegravir (DTG)-containing antiretroviral therapy (ART) coverage and low viral load suppression (VLS) among children living with HIV (CLHIV). We analyzed routine facility data before and after implementation of root-cause-based solutions for improving DTG coverage, viral load (VL) testing coverage, and VLS among CLHIV. We analyzed routine data for CLHIV ≤14 years from October 2019 through September 2022. We assessed proportion of CLHIV on ART receiving DTG, VL testing coverage (CLHIV on ART with documented VL test result), and VLS (CLHIV with documented VL test result of <1,000 copies among those with test result). From October 2019 to September 2020, 52% were on a DTG-containing regimen, 48% had documented VL test results, and 64% had VLS. Site-level teams conducted a root-cause analysis and designed corresponding solutions implemented beginning October 2020: line listing and contacting eligible CLHIV to start/transition to DTG-containing regimen and collect VL samples; ART adherence support; monthly DTG stock monitoring; tracking pending VL test results through laboratory focal persons; documenting VL test results; and informing caregivers within one week if CLHIV not virally suppressed. Granular data were used to prioritize technical assistance to sites with lowest DTG coverage, VL testing coverage, and VLS. From baseline (October 2019-September 2020) to endline (October 2021-September 2022), increases were observed for DTG coverage (52% to 71%), VL testing coverage (48% to 90%), and VLS (64% to 82%). Age-disaggregated data showed positive trends. Root-cause-based solutions and granular data use increased DTG coverage, resulting in increased VL testing and VLS among CLHIV. These interventions should be scaled and become the national standard of care.

Crafting digital business ecosystems for cultural and creative industries

The Cultural and Creative Industries (CCI) thrive on innovation and creativity, necessitating robust cross-domain collaboration among diverse stakeholders. However, the current state of CCI co-creation mechanisms is marked by inadequacies. The primary objective is to provide practical and effective strategic guidance for co-creation endeavors within the dynamic CCI landscape. This study employs the Root Cause Analysis (RCA) method to identify and analyze critical elements for industrial co-creation, offering a comprehensive framework for understanding the intricacies of co-creation processes. The Cultural and Creative Industries Digital Business Ecosystem (CCI-DBE) model is then developed to encompass four foundational pillars: participation of multiple stakeholders, mechanism of co-creation, uniqueness of consumer experience, and output of co-created value. Participation of multiple stakeholders recognizes the importance of integrating perspectives from content creators, other companies, suppliers, and customers. The mechanism of co-creation delves into the necessity of a robust platform, supported by technological infrastructure, to facilitate seamless resource and knowledge exchange. The uniqueness of consumer experience emphasizes the need for tailoring offerings to meet consumers' unique experiential and meaningful needs. Output of co-created value focuses on enhancing product novelty, resource sharing, communication efficiency, information interaction, and cross-domain integration. This CCI-DBE model not only contributes to academic discourse but also provides actionable insights for practitioners seeking to navigate and enhance the co-creation process within the evolving CCI landscape. It stands as a valuable guide for fostering innovation, collaboration, and strategic alignment in the CCI sector.

LogRule: Efficient Structured Log Mining for Root Cause Analysis

Accurate, timely Root Cause Analysis (RCA) is essential to successful IT operations as a primary step to incident remediation. RCA automation using data mining techniques in large heterogeneous systems is, however, a challenging task, because it requires correlating multimodal information across various data sources. An increasing number of services are migrating to structured logging to enable automated monitoring and debugging of complex large-scale systems. In this paper, we leverage structured logs and association rule mining (ARM) to automate RCA. We propose the LogRule algorithm, which automatically analyzes structured logs to generate a list of explanations for an event of interest. It achieves 0.921 F1-score for the diagnosis task, while computing results 37x faster compared to the state-of-the-art solution based on FP-growth, making it a time-efficient, accurate, and interpretable ARM-based RCA algorithm. Evaluation results show that LogRule enables RCA in complex multidimensional datasets, where the execution time of the current state-of-the-art algorithm is prohibitively large.