Root Couse analysis (Ishikawa diagram) and Patient Safety

Fatima Yousef Ali Ghethan

Abstract

Root Couse analysis (Ishikawa diagram) and Patient Safety

Introduction: Root cause analysis (RCA) is a structured and systematic investigation of adverse events or narrow escapes that determine what happened, the root cause, and what can be done to prevent recurrence. -certified medical institutions are required to perform and submit RCA for all sentinel events and significant error . Action plan for this improvement. It outlines the five steps an organization should take to implement RCA. What is a Fishbone Diagram? The fishbone graph, too known as the Ishikawa graph, could be a visual strategy of root cause investigation that classifies causal relationships into categories. , It got to be well known within the 1960s, and the Ishikawa chart was utilized as the premise. Quality control apparatus by Kaoru Ishikawa of the College of Tokyo. It is considered portion of today's seven fundamental quality control apparatuses. Over time, it was called a fishbone chart since it takes after a fish skeleton set on the side. The issue itself emerges within the mouth. Each bone provided to the spine of a angle speaks to a specific category of potential causes of the issue. Under each category is where you add elements that could affect the process associated with that cause. It is worth noting that each category may also have various sub-causes as well. For a great example, see the American Society for Quality (ASQ) glossary entry on fishbone diagrams. Possible causes of variation may be numerous, but they will invariably fall into the following categories: Find ways to ensure that people involved in a process know what to do and when to do it. Methodologies: Here, you will consider the need for policies, rules, regulations, or procedures to ensure consistent quality. Machinery: This could be anything from assembly line robots to tools or even computers. Materials: The materials needed to produce a quality product cannot be overlooked. Measurements: How is the process measured and monitored to evaluate quality? The Environment: This includes anything outside the company’s control that may affect results. When drawing up your fishbone diagram, you can use these six categories to feed into the “spine” of your fish skeleton drawing. Similar mini-fish bones attached to the line indicating the category under consideration can indicate the sub-factors. A fishbone diagram is a simple yet powerful way to brainstorm potential causes of problems and how they interact. Using one during your next brainstorming session can help you narrow in on the root cause of problems, giving you a holistic look at quality issues and where to focus your problem solving. Once you’ve identified the root cause, the next step is eliminating the chance of recurrence. The corrective action is just the start, as it’s essential to check back in on problems to ensure the fix is still in place. A layered process audit program and automated platform like EASE can help, giving you the ability to easily add questions based on corrective actions and report on findings immediately. Ultimately, this combination of problem-solving, corrective action and high-frequency audits are key to continuous improvement, also providing a framework for a culture of quality.

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