PPT-Root Cause Analysis(RCA)

Cardiac arrest after spinal anesthesia in Orthopedic surgery พญโสภต เหลาชย 5 มย58 Hypotension Severe bradycardia Cardiac arrest Problems Cardiac Arrest During Spinal Anesthesia Common Mechanisms and Strategies for Prevention. We offer the following analysis services: Failure Analysis / Condition Assessment / Life Assessment; Replication Tape Evaluation. 83 117 brPage 10br Example 210 120 90 brPage 11br Imaginary axis crossing point Note sxj o Example kG brPage 12br r r Example brPage 13br Grants Rule Note Ps kZs sas as asa brPage 14br Example 57360f of brPage 15br ds dp brPage 16br Example of brPage Numerous tools available to assist with identification of root cause. Fishbone (Ishikawa) charts. Process mapping. Failure modes effect analysis. Statistical process control. The 5 Whys. Process Improvement Tools. Problems . with . Root Cause Analysis. 1. Jack Harich ▪ IESA Colloquium Series . ▪ March 5, . 2014. Present methods are not working. Large-scale Social Problems. Solved. Not Solved. Serfdom. Environmental Sustainability. Numerous tools available to assist with identification of root cause. Fishbone (Ishikawa) charts. Process mapping. Failure modes effect analysis. Statistical process control. The 5 Whys. Process Improvement Tools. June 2, 2015. Root Cause Analysis. Definition. Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events.. RCA is based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms.. Mooly. . Sagiv. http://www.cs.tau.ac.il/~msagiv/courses/pa16.html. Formalities. Prerequisites: Compilers or Programming Languages. Course Grade. 10 % Lecture Summary (. latex+examples. within one week). Cause and Corrective Action . of a Problem. World Class Solutions for Global Applications. Riverhawk. Why Determine Root Cause?. Prevent problems from recurring. Reduce possible injury to personnel . EQuIP. ). Equipping Louisiana with a Quality Future.. What is this and why do it?. School-wide initiative. Engage residents and fellows in systems-based quality improvement and patient safety (QI/PS. Welcome to the session!. Objectives. Learn and be able to apply a fishbone diagram. Utilize “Why” analysis technique to uncover causes. 2. 2. “Why” Analysis . Question asking technique used to explore the cause and effect relationships underlying a particular problem. Camp Auburn Safety Annex. 971 Camp Auburn Road. Auburn University, Alabama. AC. CIDENT. 1. I. NVESTIGATION. What is an Accident. An unintended happening, mishap.. Most often an accident is any unplanned event that results in personal injury or in property damage.. Camp Auburn Safety Annex. 971 Camp Auburn Road. Auburn University, Alabama. AC. CIDENT. 1. I. NVESTIGATION. What is an Accident. An unintended happening, mishap.. Most often an accident is any unplanned event that results in personal injury or in property damage.. The Importance of Root Cause Analysis During Incident Investigation150hy was the oil on the 30oor in the 31rst place150ere there changes in conditions processes or the environment 150hat is the source Root Cause Analysis . Agenda. . Introduction to Root Cause Analysis (RCA). Keys steps for conducting root cause analyses . Assessing potential impact and actionability of addressing root causes. ROOT CAUSE ANALYSIS TOOLKIT.