1. Reliability Center, Inc.
Presents…

5. rL Solutions i-Presentation Series
Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?
Robert J. Latino
EVP – Reliability Center, Inc.

6. RCI Background
Established in 1972 as Corporate R&D Reliability Center for Allied Chemical Corporation (now Honeywell)
Established Charter to Conduct Research and Develop in the Fields of Equipment, Process and Human Reliability
As an Independent Company in 1985, Able to Spread Reliability Concept and Methods to All Industry
Researched Healthcare Culture and Market with Fay Rozovsky of The Rosovsky Group in 1997 and Revised Methodologies & Software Accordingly
Experts in Critical Thinking Framework as opposed to content within given industries

7. Recent Publications
Root Cause Analysis: Improving Performance for Bottom-Line Results, 1999, 2002 and 2006, Robert J. Latino, Taylor & Francis
The Handbook of Patient Safety Compliance, 2005, Fay Rozovsky and Dr. Jim Woods, Jossey Bass [contributing author]
Error Reduction in Healthcare, 1999, Patrice Spath Editor, Jossey Bass [contributing author]
Taking Risky Business Out of the MRI Suite, Materials Management in Healthcare Magazine, 2006, Robert J. Latino, Fay Rozovsky and Tobias Gilk
Optimizing FMEA and RCA Efforts in Healthcare, ASHRM Journal, , Volume 24, No. 3, pages 21 – 28
Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?”, Speaker, ASHRM 2005 National Conference
Intelligence and Security Informatics International Conference Proceedings, The Root Causes of Terrorism, May 2005, Department of Homeland Security (DHS)

8. Hit any key to begin at your own pace.
Here We Go!
1. Analytical Process Review
2. Analytical Tools Review
3. A Case Study: Contrasting the Difference
Hit any key to begin at your own pace.

9. Insanity is when we do the same thing over and over again and expect a different result.
- Albert Einstein
Albert Einstein was indeed a brilliant man with statements like this. How often have we seen where this statement is a “management style”?

10. (A brief movie, 7 slides – hit any key to resume.
Is This Insane?
(A brief movie, 7 slides – hit any key to resume.
What a great series of pictures to represent the prophetic words of Albert Einstein. Can you believe the mentality used in this situation? While it seems illogical now, and we think “how could they do that?”, would we have thought differently in the same position? Do we ever get trapped into the same type of thinking when doing our daily routines?

11. Brainstorming: A technique teams use to generate ideas on a particular subject. Each person in the team is asked to think creatively and write down as many ideas as possible. The ideas are not discussed or reviewed until after the brainstorming session. (ASQ)
Problem Solving: The act of defining a problem; determining the cause of the problem; identifying, prioritizing and selecting alternatives for a solution; and implementing a solution. (ASQ)
Trouble Shooting: To identify the source of a problem and apply a solution to "fix” it. ( – Synonyms: Trial-And-Error and “Band-Aid Fixes”.
Root Cause Analysis: A method used to identify and confirm the causes of performance problems or adverse trends and identify the associated corrective actions needed to prevent recurrence of the causes. Root Cause Analysis (RCA) techniques apply investigative methods to unravel complex situations to determine root causes of performance problems, identify associated causal factors, check for generic implications of an event, determine if an event is recurrent, and to recommend corrective actions. (

12. The Essential Elements Of RCA
Identification of the Real Problem to be Analyzed in the First Place
Identification of the Cause-And-Effect Relationships that Combined to Cause the Undesirable Outcome
Disciplined Data Collection and Preservation of Evidence to Support Cause-And-Effect Relationships
Identification of All Physical, Human and Latent Root Causes Associated with Undesirable Outcome
Development of Corrective Actions/Countermeasures to Prevent Same and Similar Problems in the Future
Effective Communication to Others in the Organization of Lessons Learned from Conclusions
If any one of these essential elements are missing, then we are not doing true “RCA”.

13. Common Analysis Process Tools
How Can?
Why? 1 5 2 3 4
5-WHYS
FISHBONE
LOGIC TREE

14. The 5 - Whys 5-WHYS 1 Why? 2 3 4 5 Uses Limited Cause-And-Effect
Modes Are Dependent Upon Each Other
Uses Linear Path by Asking WHY?
Promotes Use of Opinion as Fact
Promotes Belief That Only One (1) Root Cause Exists

15. The Ishikawa Fishbone Diagram
Does NOT Use Cause-And-Effect
Modes Are NOT Dependent Upon Each Other
Uses Brainstorming Primarily
Allows Use of Opinion as Fact
Promotes Belief That All Causes Are Within Categories Used
Commonly Used Categories (Fish Bones)
Methods, Machines, Materials & Manpower (4-M’s)
Place, Procedure, People & Policies (4-P’s)
Surroundings, Suppliers, Systems & Skills (4-S’s)

16. Essential Elements of RCA
Preserving Event Data
Ordering the Analysis Team
Analyzing Event Data
Communicating Findings & Recommendations
Tracking For Bottom Line Results

17. Logic Tree LOGIC TREE How Could? Why? EVENT Uses Cause-And-Effect
Modes Are Dependent Upon Each Other
Seeks All Possibilities By Asking HOW CAN?
Uses Evidence to Prove All Hypotheses
Identifies Decision Making Errors and Systems Flaws
MODES

18. Did the response to the accident/incident make the consequences worse?
Events vs. Modes
Accident/Incident X
Consequence X
Response
Did the response to the accident/incident make the consequences worse?

19. { The “Root” System HOW’s WHY’s Component Causes (Physical)
Consequences
Decision Roots
(Human)
Actions
Deficiencies in
Organizational
Systems
(Latent)
Intent

20. Some Human Factors Affecting Decision Making
Coordination
Failures
(Goals & Priorities)
Stress and
Workload
(Tunnel Vision)
Physical
Decision Roots
(Human)
Failures
To Adapt
(Procedures)
Latent
Breach
Of Defenses
(Swiss
Cheese)
Plan
Continuation
(Cues)
New
Technology
(Automation)
Normalization Of
Deviance
(Safety)
Mis-
Construction
(Mis-Perception)
Source: The Field Guide to Human Error Investigations – Sydney Dekker, Ashgate, 2002.

21. What Do You See? The Mind is a Mysterious Thing
A bird in the the hand is worth two in the bush
Perceptions are mental models developed in the brain to interpret incoming information the way it SHOULD BE versus the way that it IS.
As you will remember in class when we played this exercise, the mind sees what it thinks it should see, as opposed to what it actually is. This is important in RCA because when we interview observers we must be careful about their perceptive capabilities and falling into this trap.

22. Remember The Swiss Cheese Model? James Reasons, Human Error, 1990
Defenses (Barriers) L A T E N H U M P Y S I C

23. Contrast to A Detective’s Role
RCA ANALYSTS
DETECTIVES
“Police Scene”
Top Box
Event
Crime
Facts
Failure Modes
Hypotheses/
Verification
Leads/
Evidence
Physical Roots
(Consequences)
Forensics
(How’s)
Human Roots
(Actions)
Opportunity
Latent Roots
(Intent)
Motive
(Why’s)

24. RCA: Effectiveness vs. Efficiency vs. Strength of EvidenceHi Hi
Software Based
Disciplined RCA
Accuracy (Effectiveness)
Strength of Evidence
Problem Solving
Brainstorming Lo Lo
Trouble shooting
Hours
Months
Time (Efficiency)

25. Breadth and Depth Check
How Can?
Why? 1 5 2 3 4
Depth
5-WHYS
FISHBONE
LOGIC TREE

26. A Case Study: Endobronchial Fire
R.P.: A 65 year old man was admitted with hemoptysis in October He underwent right upper lobectomy on December 14, His final diagnosis was adenocarcinoma (T1NoMo). He received radiotherapy and chemotherapy for recurrent malignancy in August of 2002.
During this admission he was found to have bleeding from an obstructing tumor of the right main stem bronchus. Laser bronchoscopy was performed on October 7, During the procedure, endobronchial fire occurred. This was treated with prompt removal of bronchoscope and endotracheal tube. The patient was reintubated and irrigated with Normal Saline. The patient survived this event, but died in July of 2003 from metastatic lung cancer.

27. Sample 5-Why Why? Why? Why? Why? Why?
Why?
Endotracheal Fire During Bronchoscopy
Fire Initiated in Right Bronchus
Fuel Source Present in Right Bronchus
Nitrogen Used to Ventilate Chamber
Too Much Nitrogen Introduced
Why?
Why?
Why?
Why?

28. Sample Fishbone (4-M’s)
Foreign Debris/ Contamination
Scheduling/Timing Issue
Faulty Bronchoscope Source
Nitrogen Issue
Anesthetic Procedure Issue
Bronchoscopy Procedure Issue
Anesthesiologist Error
Surgeon Error
Methods
Machines
Materials
Manpower
Fiber Optic Assembly Issue
Fire in Endotrachial Tube During Bronchoscopy
Overload
Manufacturer
Inexperienced
Fatigued

29. Sample Logic Tree E = Effect E C = Cause C E C E C B A HR
OR/Patient Fire - Sentinel Event
C = Cause C
Endotrachial Fire During Yag Laser Bronchoscopy E
Fire Occurred Prior to Procedure
Fire Occurred During Procedure
Fire Occurred After
Procedure C E
Fire Initiated inside the Right Bronchus
Fire Initiated Outside the Right Bronchus C
Presence of Sufficient Oxygen
Presence of Sufficient Fuel
Presence of Sufficient Ignition Source
Sufficient Fuel Source Within Patient
Sufficient Fuel Source Introduced Into Patient
Sufficient Fuel Source On OR Staff
Sufficient Fuel Source within Atmosphere HR
Smoldering Tumor Generating Smoke Plume
Bronchoscope Source
Laser And Fiber Optic Assembly Damaged
Suff. Additional Gases Intro’d And Exposed To Laser
ET Tube Ignited
Foreign Debris B A

30. Sample Logic Tree (Cont’d)B PR LR
Laser Mis-Fired In Bronchoscopy Tube Oper. Channel
Contaminated Operating Channel
Mismanagement of Anesthetic Gas HR
Contaminated During Cleaning Process
Chemical Contamination
QC Issue - Failure to Detect Contamination HR LR
Decision to Clean Equipment Using Flammable Agent
QC Inspection in Place and Not Followed
No QC Inspection in Place
QC Inspection in Place Less Than Adequate
Decision Not in Accordance With Procedure
Decision in Accordance with Procedure
Current Procedure Inappropriate LR LR
Purchasing Pressures (Finance vs. Functionality)
No Review Process of Current Proc. When Vendors Change

31. Sample Verification Log “The Proof”

32. Evidence proves this not to be true
Filtering the Results?
Root Causes Identified
5-Whys
Fishbone
PROACT RCA
Too Much Nitrogen Introduced X
Anesthetic Procedure Issue
Evidence proves this not to be true
Fiber Optic Assembly Issue
Anesthesiologist Error
Contaminated Operating Channel of Brochoscope Source
Contamination During Cleaning Process Using Flammable Agent
Purchasing Pressures to Reduce Cost
No QC Review Process in Place When Evaluating New Vendor’s Offerings
Failure to Detect Contamination Prior to OR Use
No QC Inspection of Cleaned Instruments Prior to Use in OR
Sufficient Additional Gases Introduced and Exposed to Laser
Mismanagement of Anesthetic Gases

33. Are we using the appropriate tools for the appropriate situations?
Conclusion
We should be doing analyses to the breadth and depth of RCA when warranted simply because it is the right thing to do (chronic versus sporadic)!
If we are doing true RCA, compliance will be a by-product. If it is not, there is something very wrong with the regulations/ guidelines.
Our RCA efforts should be directly correlated to patient safety/impact on the patient.
We should thoroughly understand when it is appropriate to use RCA and when it is appropriate to use shallow cause approaches. The rigor of RCA is not appropriate for every situation that arises.
Using “shallow cause” approaches when “root cause” approaches are warranted, will likely result in the missing of key systemic root causes. This will increase the risk of recurrence.
Are we using the appropriate tools for the appropriate situations?

34. Thank you for your time and interest! QUESTIONS?
For more Information on PROACT, LEAP, FMEA, or Root Cause Analysis in Healthcare contact Gary Bonner at Reliability Center Inc. (RCI) by calling or sending an to
For more information on the rL Solutions product suite, or to learn more about how we have integrated PROACT into our solutions please contact Mike Smith at rL Solutions by calling (416) x 287 or sending an to