1. Session 3: Root Cause Analysis and Epic Failures
Dr Angela Martinez Dy

2. Session Aims and Outcomes
Understand relationship between processual failure and business failure
Identify key areas in which failure may occur
Use business and management tools to understand root causes of complex failures
Outcomes
By the end of this session and tutorial, students should be able to:
Conduct a multi-level root cause analysis on a complex business failure

3. Session Overview Five Whys Root Cause Analysis
Common method
Used in the USA
Uncover factors contributing to process of failure
Multi-level root cause analysis
Epic Failure Film

4. How To Complete The 5 Whys
Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem.
Ask Why the problem happens and write the answer down below the problem
If the answer you just provided doesn't identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down
Loop back to step 3 until the team is in agreement that the problem's root cause is identified. Again, this may take fewer or more times than five Whys

5. 5 Whys Examples
Problem Statement: Customers are unhappy because they are being shipped products that don't meet their specifications.
Why are customers being shipped bad products?
Because manufacturing built the products to a specification that is different from what the customer and the sales person agreed to.
Why did manufacturing build the products to a different specification than that of sales?
Because the sales person expedites work on the shop floor by calling the head of manufacturing directly to begin work. An error happened when the specifications were being communicated or written down.
Why does the sales person call the head of manufacturing directly to start work instead of following the procedure established in the company?
Because the "start work" form requires the sales director's approval before work can begin and slows the manufacturing process (or stops it when the director is out of the office).
Why does the form contain an approval for the sales director
Because the sales director needs to be continually updated on sales for discussions with the CEO.

6. What is Root Cause Analysis?
Root Cause Analysis (RCA) is a method that is used to address a problem or non-conformance, in order to get to the root cause of the problem

7. Why is RCA used?
Used so we can correct or eliminate the cause, and prevent the problem from recurring

8. Traditional Uses of RCA
Handling customer complaints and returned goods
Dealing with action plans following an audit
Investigating a serious incident that caused harm

9. Goal of RCA
Identify the root cause of a problem that when fixed, the problem goes away and doesn’t come back

10. Identifying the Root Cause
Incidents happen, but identifying why they happened can be very difficult
Identifying the true reason why the incident happened can be very difficult (hidden)
To identify the root cause of an incident, we must be
Focused and open-minded
Patient and quick
Relentless with our investigation

11. Dangers with RCA
If we do a poor job of identifying the root causes of our incident we may not recognise the true issues that resulted in the incident

12. How to carry out a RCA
There are many reasons why an incident happened and identifying the contributing factors can be difficult
Examples of methods used to carry out a RCA
Cause & effect – Ishikawa Diagram (Fishbone)
Events & causal factors analysis
Fault tree analysis
Causal factors charting
Story telling method

13. Sequence of Events Checking Collecting from Dispensing Chemotherapy
ward fridge
Checking
Chemotherapy
Cytosine
Vincristine
Administration of

14. Cause & Effect Analysis
Employs a FISHBONE DIAGRAM to help identify contributing factors

15. Causal Factors INCIDENT Management & Organisational Factors
Task & Technology Factors
Team Factors
INCIDENT
External Factors
Work / Care Environment Factors
Individual Staff Factors
Patient Factors

16. Multi-Level Causal Analysis
External Factors
MACRO
Work / Care Environment Factors
MESO
Management & Organisational Factors
INCIDENT
Task & Technology Factors
Team Factors
MICRO
Individual Staff Factors
Patient Factors

17. Examples of Contributing Factors Case: Healthcare Incident

18. Management & Organisational Factors
Lack of safety culture
No leadership presence
Unclear roles and responsibilities
Lack of explicit protocols
Lack of control of documents
Lack of dissemination of protocols
Insufficient safe storage of medicines
No formal induction process for staff
No formal staff training for staff
Employment checks

19. Team Factors Lack of communication verbal & written
Lack of multidisciplinary approach
Lack of communication verbal & written
Lack of defined roles and responsibilities
Lack of skilled staff on duty to support others
Hierarchical culture
Lack of local induction

20. Task & Technology Factors
No clear protocols & duplication of protocols
No relevant training program
Syringe fittings
No assessment of competence
Unclear labelling of drugs
Poor packaging of drugs
Incorrect storage of equipment
Pharmacy logs

21. Patient Factors
Patient attended clinic at the wrong time

22. Individual Staff Factors
New to the hospital
New to the ward
No senior staff on duty
Lack of competency of doctors to undertake the procedure
Failure to comply with procedure
Nurses absolving themselves of all responsibility
Pharmacy did not challenge ward ordering/collection protocols
Lack of concentration
Lack of experienced nursing staff on duty

23. Work/Care Environment Factors
Inadequate storage of medications
Lack of competent staff to support the open door culture
Lack of training/induction
Two diary systems running at the same time but did not correlate
Lack of ongoing training
Lack of competency assessment
Hierarchical culture

24. External Factors Patient
International protocol for administration of chemotherapy
No standardised / formal training for medical staff in the administration of chemotherapy
Manufacturers of syringe
No learning from previous incidents internationally

25. Outcome of the RCA Toft 2001 However……………
The evidence presented to the inquiry suggested that the adverse incident that led to this death of the patient was not caused by one or even several human errors but by a far more complex amalgam of human, organisational, technical and social interactions.
Toft 2001
However……………

26. RCA identified that there was one risk reduction strategy that would have prevented this incident. This was the re-design of the syringe and catheter connection used for the administration of the drug.

28. Enron: The Smartest Guys in the Room
Enron scandal
Massive US energy company filed for bankruptcy in due to fraudulent and criminal activity
misleading customers, unethical practices, ‘cooking the books’
Not all failures will be due to ethical misconduct – but some will!
More information:

29. As you Watch the Film Take notes and pay close attention to:
Macro-economic conditions in which the company was working
Key players within the company and critical decisions
Other players outside the company – who else had a role in this failure?
Management approach/style. Does this resemble any of the ‘frog typology?’