July 10, 2019 | Mark Paradies

Thorough and Credible Root Cause Analysis – How Can You Achieve It?

Thorough & Credible Root Cause Analysis

Do you want your root cause analysis to be thorough and credible? Then read on to learn how to achieve your goal.

This post will explain:

  • The fundamentals of root cause analysis
  • How to make your root cause analysis thorough
  • How to demonstrate that your root cause analysis is credible
  • Developing effective corrective actions
  • How to learn more

Start with Root Cause Analysis Fundamentals

We have already written and have a video about the fundamentals of root cause analysis. Read more here or watch the video below…

The fundamentals teach you that you need a:

  • Definition for a root cause
  • A systematic process that helps lead you to root causes
  • Training in that process and other fundamentals of incident investigation
  • Software to make the process easy to use
  • Continuous improvement of your skills (including grading the results of your root cause analyses)
  • Trending of your results to find Generic Causes.

Those fundamentals will get you far down the road to thorough and credible root cause analysis.

Thorough Root Cause Analysis

To have a thorough root cause analysis you need to have a complete understanding of what happened that resulted in the incident (the adverse consequences).

This starting point is needed regardless of the type of incident being investigated. For example, the incident could be a:

  • hospital sentinel event
  • oil drilling rig blowout
  • refinery fire
  • release of radiation at a nuclear power plant
  • failure of the grid resulting in a power outage
  • drug manufacturing quality escape
  • crane collapse at a construction site
  • major piece of equipment that fails unexpectedly causing a production outage
  • or any significant near-miss that could have led to a more serious incident (a precursor incident)

To help you understand the information you collect, we recommend developing a SnapCharT® (See an example below).

The SnapCharT® above is a simple “misadministration of medication” that is still being developed. Much information needs to be collected and that information will be added to the SnapCharT® as it is developed. Adding the needed information can help you achieve a thorough and credible root cause analysis that is required by The Joint Commission.

Below is another simple incident. This time it is a lost time injury – a sprained ankle. This example shows that even a simple incident can have many details that lead to the incident. In this case, construction traffic using a parking lot for access to a construction site, a failed breaker, an employee who is walking across a dark parking lot, and a failure to fix or barricade and mark a pothole in the parking lot.

This shows the in-depth investigation that is needed to understand what happened to develop a thorough root cause analysis. But we aren’t done yet. We still need to find real, fixable root causes for each of the Causal Factors marked with a triangle in the SnapCharT® above.

To do this, we use a tool in the TapRooT® System called the Root Cause Tree® Diagram.

The diagram leads an investigator to the fixable causes of equipment and human performance Causal Factors.

How does the Root Cause Diagram work and what does it look like? That’s the topic of a whole chapter in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, and we won’t repeat all that information here.

Click on the book above to order the book, the Root Cause Tree® Diagram (laminated), the Root Cause Tree® Dictionary, and the Corrective Action Helper® Guide. If you want to see how the Root Cause Tree® Diagram is applied to Patient Safety incidents, we have a specialized book for that – Improving Patient Safety with TapRooT® Root Cause Analysis. Click on the book below to order that book…

 

Credible Root Cause Analysis

Having found the real, fixable root causes using the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary, you will make sure that your evidence used to determine the root causes is documented on your SnapCharT®. Then you can demonstrate how credible your root cause analysis is by showing how the incident happened and what caused it on an easy to understand graphic – the SnapCharT®.

But There is More!

You now have a thorough, credible root cause analysis but you aren’t done. You need to develop effective corrective actions. That’s why we developed the Corrective Action Helper® Guide and the Corrective Action Helper® Module of the TapRooT® IV Software.

Once you apply the guide, you have a thorough, credible root cause analysis and corrective actions that you can present to management and get approval to apply what you have learned to improve performance and prevent future incidents.

Learn to Achieve Thorough, Credible Root Cause Analysis

Are you interested in learning more about a thorough credible root cause analysis? Then attend one of our courses…

First, there is the 2-Day TapRooT® Root Cause Analysis Course. It was developed to teach the essential techniques that investigators need to quickly investigate low-to-medium risk incidents. See the locations and dates for public 2-Day TapRooT® Courses being held around the world at this link:

https://www.taproot.com/store/2-Day-Courses/

Second, we offer the 5-Day Advanced Root Cause Analysis Team Leader Course. It teaches the essential techniques plus even more advanced techniques needed to investigate major accidents. See the locations and dates for public 5-Day TapRooT® Courses being held around the world at this link:

https://www.taproot.com/store/5-Day-Courses/

Do you need specialized training to improve your information collection, investigations, corrective actions, or analysis of incident trends? We offer courses in:

  • Equifactor® Equipment Troubleshooting and Root Cause Analysis
  • Interviewing and Evidence Collection
  • Stopping Human Error
  • Trending to Manage Performance
  • Root Cause Analysis for Audits
  • Mistake Proofing & Effective Corrective Actions
  • Improving Patient Safety with TapRooT® Root Cause Analysis

Click on the link below for more information:

https://www.taproot.com/courses

Don’t wait!

You can’t afford incomplete, ineffective root cause analysis. You need your investigations to be thorough and credible. Click on one of the links above, pick your course, and get registered before the course of your choosing fills up. OR sponsor a course at your site. Contact us for more details and a quote by CLICKING HERE.

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Categories
Investigations, Patient Safety & Healthcare, Root Cause Analysis, Root Cause Analysis Tips
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