RCA on Root Cause Analysis – reblogged from Safety Dog’s blog

RCA on Root Cause Analysis – reblogged from Safety Dog’s Blog

The post linked above talks about the barriers to doing RCAs [1] and also how to make them more effective, but also mentions the fact that there doesn’t appear to have been a great deal of evaluation (in an evidence-based medicine sense) of their use in healthcare.

“In a 2008 interview with Robert Watcher, Albert Wu  said “Although we are living in an era of evidence-based medicine, root cause analysis was widely adopted by the medical community in the 1990s without the benefit of much evidence. Every institution now conducts root cause analysis. Thousands of health care workers devote many hours to conducting these analyses, yet root cause analysis has never really been evaluated.”
(AHRQ, http://webmm.ahrq.gov/perspective.aspx?perspectiveID=61)

CHI+MED has been looking at how formal verification tools [2], such as PVS [3] can be used to analyse what information was available to people around the time of an incident, and how information moves through the system.

We have used PVS to re-analyse part of an accident report and found that the tool helped us to “find issues beyond that related to direct causes of the particular incident […]”. The tool and modelling approach were valuable in that they “can lead to insight that would help guide an incident investigator.”

• Masci P, Huang H, Curzon P and Harrison M (2012) Using PVS to Investigate Incidents through the Lens of Distributed Cognition presented at 4th NASA Formal Methods Symposium, Norfolk, Virginia, USA.

Notes
[1] An RCA is a root cause analysis, used in investigating medical, and other incidents, to try and find out what caused the incident.
[2] formal methods are “mathematical techniques for developing computer-based software and hardware systems.”
[3] PVS – prototype verification system

Other uses for PVS
• Masci P, Furniss D, Curzon P, Harrison M and Blandford A (2012) Supporting field investigators with PVS: A case study in the healthcare domain. Proceedings of 4th International Workshop on Software Engineering for Resilient Systems (SERENE 2012), 150–164. Lecture Notes in Computer Science, vol. 7527. Springer  – here PVS is being used to help researchers who are undertaking field studies in a healthcare setting, and who are observing the setting under normal circumstances.

Further reading on other methods for investigating incidents
• Svenson, O (2000) Accident Analysis and Barrier Function (AEB) Method: Manual for Incident Analysis (SKI Report 00:6) ISSN 1104-1374 | ISRN SKI-R–00/6–SE – this paper looks at the AEB method, which “models an accident or incident as a series of interactions between human and technical systems. In the sequence of human and technical errors leading to an accident there is, in principle, a possibility to arrest the development between each two successive errors” using examples from road traffic, a nuclear power plant and medical (dialysis) domains.

Scientific methods for accident investigation presented by Dmitri Zotov at the ANZSASI conference regional seminar in 2000 – this focuses on air accident investigations and the strategies used in gathering data and their subsequent analysis.

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