Root-cause analysis is an analysis technique that is used to understand the cause of an identified problem. It is used to explain to the risk owner why the event might occur using a structured approach. It should also investigate how certain things could have gone wrong, which would help in identifying the cause of the problem and interim breakdowns. The structured approach offers excellent clarity in what risk mitigation actions ought to be taken. Diagram 1.1 presented below plays an integral role in identifying the root-causes of a problem or risk.
A work group approach should be adopted in establishing the root-cause of a problem when the risk is complex. It works best when participants know the project and subject areas. Root- cause analysis is applicable when one wants to establish the cause of a problem with the intention of using the information gathered to develop a corrective plan. The technique entails uncovering the root-cause or causes of the problem, identification of weaknesses or other contributing factors which are not nonconformance ("Introduction to the Field of Root Cause Analysis," 2006). One should also understand the process surrounding the problem and any supporting process.
In the case study, the patient was subjected to a medical error by being overdosed by vasopressin. The impact of the mistake was huge on the patient since they rapidly deteriorated. Medical errors are often rampant in health institutions, but the ones that are subjected to root-cause analysis are those that are relatively big and have adverse effects on the outcome of patients. The problem should be investigated since it might have caused a number of deaths without the knowledge of medical practitioners.
In a health institution, the root-cause analysis is an investigation of serious adverse events that are performed by a team that is specialized in the area of the inquiry and whose members are not involved in the error. The primary objective of the group is to determine what happened, why it happened and what could be done to mitigate the challenge. The hospital should not just focus on the individual who prescribed the wrong dosage but also broadens its focus in assessing the environment that entails the staff, medication ordering process, time and other conditions that describes a hospital environment. The root-cause analysis would help in changing the understanding of analysis of adverse event that are generated by individual human mistakes that seem to be minor.
Goals and limitations of root-cause analysis
The purpose of root-cause analysis to find out what happened, how it happened and what can be done to prevent it from happening again. Root-cause analysis is mainly used as a reactive method to identify the causes of events, revealing problems and recommending measures to be taken to mitigate the problem (Barsalou, 2015). However, RCA at times ends in exasperation or exacerbation due to its failure to identify the source of the problem or identification of the wrong cause of a problem. The fault could be attributed to the two critical assumptions that RCA makes. First, it assumes that the causes of an issue that has no internal structure are possible (Mobley, 1999). Secondly, it implies that these atomic causes are independent and adjustable forces. These two assumptions could be invalid based on the human systems. For example, the hypothesis of atomic causes cannot explain when I have a project that is late since I keep on changing things and I have decided to add resources to speed it up. Adding funds is a change on its own and the further change delays the project.
Steps of conducting a root-cause analysis
Root-cause analysis has five identifiable steps. These steps are: Step one entails identification of the problem. In this stage, one describes what they see. The project team set the vision, identifies the problem and collect data that is needed in understanding the current situation. The information is used in determining the causal factors. In identifying causal factors, one should ask what problems relate to the main issue, what conditions allow the problem to occur and what sequence of events lead to the problem. During this step, numerous causal factors should be identified, if possible. Phase two entails identification of the cause of the problem. The leading causes of a problem are not always found in the most apparent causes hence one should dig deeper to exhaust all the responses or cover all the essential roots (Andersen & Fagerhaug, 2014). There different methods that can be used in identifying the cause of a problem. The primary process is the construction of a root-cause tree. In this process, one should start with the problem and brainstorm causal factors for the problem by asking why (Wiklund, Dwyer, & Davis, 2016). The should connect their findings to a logical cause and effect order until they arrive at the root of the problem. The last step is to recommend and implement solutions. In this step, one analyzes the cause and effect process and identifies the changes that are needed for various systems.
In conclusion, the root-cause analysis is a technique that plays an integral role in the identification of the causes of a problem. Using a structured, the method explains why an event occurred and its interim breakdowns. There are several steps that RCA follows to achieve an efficient outcome. These steps are structured and cannot be bypassed in the process of determining the root-cause of a problem. RCA has limitations that make it at times to be ineffective. At times RCA fails to identify the source of a problem which results in anger and frustration by the victims of the situation. These failures could be attributed to the two assumptions that the technique makes in its operations. The premises are; the causes of a problem that has no internal structure are possible, and the atomic causes are independent and adjustable causes.
Andersen, B., & Fagerhaug, T. (2014). ASQ pocket guide to root-cause analysis.
Barsalou, M. A. (2015). Root-cause analysis: A step-by-step guide to using the right tool at the right time.
Introduction to the Field of Root Cause Analysis. (2006). Root Cause Analysis, 17-26. doi:10.1201/9781420006117.ch2Mobley, K. (1999). RETRACTED: Root Cause Failure Analysis Methodology. Root Cause Failure Analysis, 14-57. doi:10.1016/b978-075067158-3/50002-8
Wiklund, M. E., Dwyer, A., & Davis, E. (2016). Medical device use error: Root-cause analysis.
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