2016 Risk Course Book

4. CAUSAL ANALYSIS

- Various methodologies - Completing the information - Interviews - Consulting documents/logs - Use of objectivity Methodologies Advantages Root Cause Analysis (RCA) 5 Whys? meth ds = systematic questioning to identify the main causes • Schematic description • Easy to implement Root Cause Analysis (RCA) Ishikawa diagram = focus on five to seven aspects: materials, method, manpower, environment, etc

Disadvantages

• Partial analysis due to the focus on identifying links between the event's causes • No chronology No representation of logical relationships • No chronology • No representation of logical relationships • No chronology • The actions to be taken are more complicated (addressing latent errors)

Root Cause Analysis (RCA) HFACTS

= Method based on systematic questioning to identify the main causes (Includes supervision failures) = Method designed for a hospital's clinical activities -steered towards finding latent errors in organisation and governance = Schematic description and reconstruction of the chronology of the facts = Systemic method of analysis and recreates the context surrounding the event (=ALARM + fault tree)

ALARM

Causal/fault Tree Analysis

Factors not ranked

ORION®

Initial analysis require support