More on root cause

The Expert Answers section in the September QP ("Bank error") included a question and answer on conducting root cause analysis (RCA) for a hospital blood bank error: a misplaced sample. The answer was a good introduction to RCA, but given that the question came from someone who is new to her role, a little broader information might be helpful.

Based on the problem statement, a pure focus on RCA for the one event may miss the true problem. And even though the question was about RCA, the goal or outcome must be effective problem solving.

It’s important to see the failure within its environment, not as an isolated event. As such, in addition to the good suggestions in the answer, the team should be asking at least some of the following questions that explore two areas:

The universe of the failure:

  • What is the failure rate for this type of failure?
  • When was the most recent such failure?
  • Was it analyzed, and is the analysis documented for the team to review?
  • Do you know the actual failure rate?  How many times does this failure (a misplaced sample) occur but is not reported? If a sample was misplaced but found after a search, would that be reported?

The system:

  • Is the system documented?
  • Is training documented?
  • Is there periodic retraining?
  • Is the system overly complex and error prone?
  • Is simple technology, such as barcoding, employed to reduce errors?
  • Is the system understood?

I included that final question because the problem suggests confusion as to whether samples are filed based on the date drawn or the date tested.

RCA is a worthy element of problem solving, and the advice given was good. But to get the best outcome, the elements mentioned earlier—understanding the failure conditions and understanding the system—probably should come first, before you start focusing on RCA. Only then will RCA be most effective because it will be embedded in an overall problem-solving process.

Tom DuBois
Glens Falls, NY

Personal change

It was fantastic to see the core issues that hamper successful transformation and change management put forward so succinctly in "Change Ability" (August 2012).

One other aspect of a successful transformation is the person driving the change. All the attributes stated in the article, absolute clarity of purpose for driving the change and unconditional respect for all need to be part of the change manager to make the effort a success for the organization and its employees. Thanks for a brilliant article.

Vic Manuja
Ryde, Australia

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