What is a Causal Factor?
What is a Causal Factor?
The term “Causal Factor” came from the System Safety Development Center in Idaho Falls, Idaho. It was part of an investigation tool called “Events and Causal Factors Charting.” We got permission to use the tool and the original documentation in 1988 as part of the original version of TapRooT®. But as time went on, we simplified and modified the tool and eventually renamed it “SnapCharT®.” When we did that, we decided we needed to define a “Causal Factor.” Our definition is:
A mistake, error, or failure that directly leads to
(or causes) an Incident (the circle on the SnapCharT®) or
fails to mitigate the consequences of the original error.
How to Find a Causal Factor
Our Causal Factor definition has served us well but, over the years, we have taught several different methods of identifying Causal Factors. These methods include:
- Direct observation
- The “so what” method
- Safeguard Analysis
- The three-question method
But in 2020 we will start teaching a new method to find Causal Factors. What is it? A set of questions to ask depending on the type of incident you are investigating.
Causal Factor Worksheets
What type of questions sets (worksheets) did we develop?
- One for Equipment Failure-related Incidents
- One for Patient Safety-related Incidents
- One for Quality-related Incidents
- One for Safety-related Incidents
If you have an incident that doesn’t fit one of these categories, you can:
- Go back to the Three Question Method
- Use the check sheet or sheets that most closely match your Incident.
- Develop a custom check sheet based on the other sheets and the Three Question Method
But we have found that the Causal Factor Worksheets are very effective for identifying Causal factors for both new TapRooT® Users and experienced TapRooT® Investigators.
Safety Causal Factor Worksheet
What does a Causal Factor Worksheet look like? Here is a draft of the Safety Causal Factor Worksheet:
Learn More About Causal Factor Worksheets
Want to learn more about these Causal Factor Worksheets? You have two options.
Second, you can attend either the:
- 2-Day TapRooT® Root Cause Analysis Training, or the
- 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, or the
- 2-Day Equifactor® Equipment Troubleshooting and TapRooT® Root Cause Analysis Course.
See the upcoming public course dates at:
Or CONTACT US to schedule a course at your site.
Note: The Safety Causal Factor Worksheet above is copyrighted material and is used here by permission. Duplication is prohibited.