What is a Causal Factor? (Updated)
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 this Autumn 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
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? Attend the 2020 Global TapRooT® Summit and go to the Using Causal Factor Worksheets best practices session in the Improving Investigations Track. Alex Paradies and Tim Diggs will teach you to use these new tools.
When is the 2020 Global TapRooT® Summit being held? March 9-13.
Where is the 2020 Global TapRooT® Summit being held? The Horseshoe Bay Resort near Austin, Texas.
How much does it cost to attend? See below to attend just the Summit (March 11-13) or the Summit and a Pre-Summit Course (March 9-13)…
Don’t forget, this is a Summit where you are guaranteed to learn.
Attend the 2020 Global TapRooT® Summit. Go back to work and implement your road map to success. If you don’t save 10 times the cost of your attendance at the Summit, let us know and return your Summit materials and we will refund 100% of the Summit registration fee. This guarantee shows how certain we are that you will learn valuable best practices to take your facility’s performance to the next level.
Now is the time to register. Use the link below…
Note: The Safety Causal Factor Worksheet above is copyrighted material and is used here by permission. Duplication is prohibited.