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Root Cause Analysis

Steps for root cause analysis

Investigate events

Reconstruct events

Analyze causes

Develop action plans

Report RCA process and findings

Langkah RCA

investigasi kejadian,

rekonstruksi kejadian,

analisis sebab, menyusun rencana tindakan, dan

melaporkan proses analisis dan temuan.

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Investigate events

Define the problem

Collect pertinent evidence Conduct interview

Review event environment

Determine contributing factors

Establish a chain of events

Investigasi kejadian

menentukan masalah,

mengumpulkan bukti-bukti yang nyata,

melakukan wawancara,

meneliti lingkungan kejadian,

mengenali faktor-faktor yang berkontribusiterhadap timbulnya kejadian,

menggambarkan rantai terjadinya

kejadian.

Reconstruct events

Define events preceding the adverse

event or near miss

Determine actions and conditions leading

up to these events by developing a causaltree

Continue until you have identifiedunderlying systems causes or until it isunreasonable to go further

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Rekonstruksi kejadian

mengenali kejadian-kejadian yang

mengawali terjadinya adverse eventataupun near miss,

melakukan analisis dengan menggunakanpohon masalah untuk mengetahuikegiatan atau kondisi yang menyebabkantimbul kejadian,

lanjutkan sehingga dapat dikenali sistemyang melatar belakangi timbulnya kejadianatau sampai tidak beralasan lagi untuk

Analyze causes

Identify root causes within your causal tree

Develop root cause statement

Analisis penyebab

mengidentifikasi akar-akar penyebab,

rumuskan pernyataan akar masalah

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Develop action plans

Identify strategies that are appropriate to

the causes identified and acceptable to theorganization and to those who will be

involve in the changes

Develop a plan for addressing each rootcause and for measuring effectiveness ofintervention

Gain agreement form organizationalleadership regarding actions to be taken

Susun rencana tindakan

menetapkan strategi yang tepat untuk

mengatasi penyebab yang diidentifikasi,dan dapat diterima oleh pihak yang terkaitdengan kejadian.

Rencana tindakan disusun untuk tiap akarpenyebab kejadian dan pengukuran untukmenilai efektifitas tindakan thd akarpenyebab

Dapatkan persetujuan dari kepemimpinandalam organisasi

Record RCA process andfindings

Record the process and tools uses

The cost of the process

A summary of the events The investigation and analysis process

Findings

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Catat dan laporkan

Catat proses dan alat yang digunakan

Biaya yang dibutuhkan Ringkasan kejadian

Proses investigasi dan analisis

Temuan

Understanding causes of events

Active failure: an intentional violation

committed by an individual

Latent condition: a breakdown in process

or systems:

lack of education,

failure to follow procedure,

equipment defect,

poor design, etc

Memahami penyebab kejadian

Kegagalan aktif: pelanggaran yang

sengaja dilakukan oleh seseorang

Kondisi laten: breakdown dari proses atau

sistem:

Kurangnya pendidikan

Gagal mengikuti prosedur

Alat yang rusak

Disain yang tidak tepat, dsb

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Philosophical viewpoints on humanerrors

Human error is not the cause of events, it

is a symptom of deeper troubles in thesystem

Human error is not the conclusion of aninvestigation, it is the beginning

Events are the result of multiple causes

21 steps of RCA (Joint commission)

Communicate the results21

Take additional action20

Run chart, control chart, histogramEvaluate implementation of improvement plan19

Develop measures of effectiveness and ensure their success18

PDCA, criticalpathImplement the Improvement Plan17

Ensure acceptability of the action plan16

Gantt chartDesign improvements15

Evaluate Proposes Improvement Actions14

Brainstorm, flow chart, cause effect diagramFormulate improvement actions13

FMEAExplore & identify risk-reduction strategies12

Confirm root causes11

Prune the list of root causes10

Flow chart, cause effect diag, fmea, treeanalysis, barrier analysis

Identify which systems are involved (the root causes)9

Gantt chartDesign and implement interim changes8

See how to develop indicatorsMeasure, collect and assess data on proximate and underlyingcauses

7

Brainstorm, affinity diag, cause-effect diagramIdentify other contributing factors6

Controlchart, tree analysis, FMEAIdentify contributing factors5

Flow chart, timelineDetermine what happen4

Braintorm, flowchart, pareto, scatter, affinitydiagram, etc

Study the problem3

Brainstorming, multivoting, FMEADefine the problem2

Size fewer than 10Organize a team1

Note and ToolsDescriptionsSteps