Root Cause Analysis (root + cause_analysis)

Distribution by Scientific Domains


Selected Abstracts


Use root cause analysis to understand and improve process safety culture

PROCESS SAFETY PROGRESS, Issue 4 2008
Ian S. Sutton
Abstract This article describes the topics of root cause analysis and company culture. An evaluation of the root causes of incidents can help identify areas where the culture requires improvement. In addition, an analysis of the nature of root cause can help companies understand their culture. Following an incident, root cause analysis can be conducted for at least four levels of management, (a) line supervision, (b) facility management, (c) executive management, and (d) professionals who write and then implement regulations and standards. This article makes a distinction between root causes for occupational losses and for major process accidents; it emphasizes the teachings that improve one does not automatically improve the other. In other words, a root cause analysis program that addresses the behaviors that correct occupational safety problems may not help correct those behaviors that cause process safety incidents. Examples of how root cause analysis can help a company understand and improve its culture are provided. For instance, companies should recognize the need for both training and education. If process risk is to be reduced, employees need to be educated as well as trained because education creates new behaviors that allow for improved root cause analysis and the aversion of major events. © 2008 American Institute of Chemical Engineers Process Saf Prog 2008 [source]


AL02 ADVERSE EVENTS: OUR RESPONSIBILITY FOR REPORTING, REVIEWING AND RESPONDING

ANZ JOURNAL OF SURGERY, Issue 2009
D. A. Watters
An adverse event is defined as unintentional harm (to a patient) arising from an episode of healthcare and not due to the disease process itself. Surgical adverse events include death, unplanned reoperation, unplanned readmission, unplanned ICU readmission, medication errors and side-effects, falls, pressure ulcers, hospital acquired infection, and inadvertent injury during surgery. Adverse events occur in around 10% of general surgical cases. The rates also vary between specialties. Reporting: , Adverse events need to be reported through both a hospital incident reporting system (eg Riskman) and through surgical audit. Each adverse event should be graded using a Severity Assessment Code (1,4) on the basis of its effect on the patient or hospital service, and the likelihood of it recurring. Some of the more severe events will trigger an entry on the risk register, making service managers responsible for action. Reviewing: , The opportunity must be seized to improve system issues. An investigation (eg root cause analysis) should be conducted in an atmosphere of ,no-blame' with engagement of and consultation with the major stakeholders who are responsible for delivering solutions. Training in system-wide approaches and teamwork can be invaluable. Responding: , The response needs to recognise the needs of the patient who has been harmed. There should be an honest and frank discussion with the patient and/or their family, acknowledging their suffering with empathy and an apology should be offered without necessarily admitting any liability. Open disclosure has the potential to reduce risk of litigation. Surgeons need to engage in reporting, reviewing and responding if the rate of adverse events is to be reduced. [source]


Application of Multivariate Data Analysis for Identification and Successful Resolution of a Root Cause for a Bioprocessing Application

BIOTECHNOLOGY PROGRESS, Issue 3 2008
Alime Ozlem Kirdar
Multivariate Data Analysis (MVDA) can be used for supporting key activities required for successful bioprocessing. These activities include process characterization, process scale-up, process monitoring, fault diagnosis and root cause analysis. This paper examines an application of MVDA towards root cause analysis for identifying scale-up differences and parameter interactions that adversely impact cell culture process performance. Multivariate data analysis and modeling were performed using data from small-scale (2 L), pilot-scale (2,000 L) and commercial-scale (15,000 L) batches. The input parameters examined included bioreactor pCO2, glucose, lactate, ammonium, raw materials and seed inocula. The output parameters included product attributes, product titer, viable cell density, cell viability and osmolality. Time course performance variables (daily, initial, peak and end point) were also evaluated. Application of MVDA as a diagnostic tool was successful in identifying the root cause and designing experimental conditions to demonstrate and correct it. Process parameters and their interactions that adversely impact cell culture performance and product attributes were successfully identified. MVDA was successfully used as an effective tool for collating process knowledge and increasing process understanding. [source]


Rectal cancer: involved circumferential resection margin , a root cause analysis

COLORECTAL DISEASE, Issue 5 2009
H. Youssef
Abstract Introduction, An involved circumferential resection margin (CRM) following surgery for rectal cancer is the strongest predictor of local recurrence and may represent a failure of the multidisciplinary team (MDT) process. Aim of study, The study analyses the causes of positive CRM in patients undergoing elective surgery for rectal cancer with respect to the decision-making process of the MDT, preoperative rectal cancer staging and surgical technique. Method, From March 2002 to September 2005, data were collected prospectively on all patients undergoing elective rectal cancer surgery with curative intent. The data on all patients identified with positive CRM were analysed. Results, Of 158 patients (male:female = 2.2:1) who underwent potentially curative surgery, 16 (10%) patients had a positive CRM on postoperative histology. Four were due to failure of the pelvic magnetic resonance imaging (MRI) staging scans to predict an involved margin, two with an equivocal CRM on MRI did not have preoperative radiotherapy, one had an inaccurate assessment of the site of primary tumour and in one intra-operative difficulty was encountered. No failure of staging or surgery was identified in the remaining eight of the 16 patients. Abdominoperineal resection (APR) was associated with a 26% positive CRM, compared with 5% for anterior resection. Conclusion, No single consistent cause was found for a positive CRM. The current MDT process and/or surgical technique may be inadequate for low rectal tumours requiring APR. [source]