Introduction to Root Cause Analysis

Methods: A comprehensive bundle of interventions was implemented incorporating the standard US Centers for Disease Control and Prevention bundle with additional measures such as root-cause analysis of all CLABSI cases, use of passive disinfection caps on vascular access ports, standardisation of weekly central venous catheter (CVC) site dressing changes, and use of antithrombotic and antimicrobial-coated CVCs with fewer lumens.

Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm.

Remaining gaps in the guidelines include ensuring that optimal endoscope-channel sample methods are used and ensuring effective root-cause analysis and remediation when contamination is detected.

Far-field spectral imaging, coupled with computer vision methods, is demonstrated as an effective inspection method for detection, classification, and root-cause analysis of manufacturing defects in large area Si nanopillar arrays.

In fact, this warranted the initiation of a root-cause analysis of the entire event led by two faculty members, one post-graduate and one technical supervisor in our blood centre.

Further, the impact of different data transfer parameters and, root-cause analysis of the resulting performance in terms of data transfer throughput and CPU utilization for different combinations of techniques is presented.

Methods Chart audits, root-cause analysis, and staff engagement informed bundle development.

Later, the root-cause analysis was performed on defective transformers to understand their failure reasons and possibilities to evade them.

Design/methodology/approach A survey was conducted to better understand patients' perceptions of ED services, lean tools such as process mapping and A3 problem-solving sheets were used to identify hidden process wastes and root-cause analysis was performed to determine the reasons of long waiting time in ED.

The main components of the constraint-based thinking approach are as follows: first, the identification of constraints or existing limitations, hindrances behind the current status quo that need to be changed; second, a root-cause analysis to understand the underlying causes for each of the identified constraints; third, a mapping of each of those causes to specific product characteristics or requirements; and, fourth, development of a minimal viable product or a prototype.

The purpose of vetting could be root-cause analysis/troubleshooting or sanity-checking/justification.

The increasing complexity of integrated systems has exacerbated the problems associated with root-cause analysis.

In addition to the electrical operating conditions, it is therefore important to also identify and characterize the climatic conditions that power converters in wind turbines are exposed to, both as a contribution to root-cause analysis and as a basis for the derivation of suitable test procedures for reliability qualification of components and systems.

METHODS Epidemiological investigation and root-cause analysis were performed.

At least 14 ineffective and inefficient activities were then carried out a root-cause analysis to determine the source of the problem that had to be eliminated.

Performance monitoring, anomaly detection, and root-cause analysis in complex cyber-physical systems (CPSs) are often highly intractable due to widely diverse operational modes, disparate data types, and complex fault propagation mechanisms.

A root-cause analysis was undertaken to find the causes of LONS in VLBW babies with central lines.

, (i) identify undetected process correlations, (ii) forecast the product quality, and (iii) perform root-cause analysis of failures or problems.

Root-cause analysis, including a lookback procedure, led us to exclude blood donors as the source of HCV transmission.

This paper presents a comprehensive root-cause analysis of this behavior in a 6.

In this work, a root-cause analysis was carried out to identify the main causes leading to squat formation in a metropolitan railway.

Without such data, a systematic root-cause analysis becomes meaningless.

Therefore, this paper provides a performance evaluation and root-cause analysis of the cross-protocol unfairness between HAS/3 and HAS/2.

The understanding and discovery of the causes of yield detractors is a complex procedure of root-cause analysis.

This raises the issue of a possible hidden cause lying behind the perceived determinants of failure; the authors, therefore, look for the root-cause of this broad noteworthy phenomenon and apply the techniques typical of “root-cause analysis”.

Root-cause analysis was performed to identify practice deficiencies.

3 They performed a root-cause analysis of CRC diagnoses among patients with IBD followed in a secondary care network between 1998 and 2019, utilising the PCCRC cause-identification framework developed by the World Endoscopy Organization.

Lean thinking can be used to improve health care organizations using such tools as the A3 form, root-cause analysis, value stream maps, Gemba walks, kaizen events, and defining standard work.

Future guidance is recommended on commissioning, adoption of local tolerances and root-cause analysis strategies to assist departments intending to implement OTM.

Our strategic plan consisted of four main components: (1) Use of quality improvement tools for quality assessment and management (Six Sigma quality improvement processes, root-cause analysis, process maps, and brain storming); (2) participate in international collaborative networks (St.

However, current fault diagnosis methods for distributed applications have drawbacks in coarse-grained fault location and inaccurate root-cause analysis.

Therefore, this paper provides a performance evaluation and root-cause analysis of the cross-protocol unfairness between HAS/3 and HAS/2.

We aimed at improving EIBF among newborns delivered at a secondary care hospital using standard quality improvement methods of root-cause analysis and the Plan-Do-Study-Act (PDSA) cycle.

After a series of investigations for root-cause analysis, the conclusion was that fracture of the tubing mechanistically is categorized as stress corrosion cracking (SCC) and is closely related to the application of phosphate-based completion fluid.

It is also shown in this study that the feature is insensitive to other types of gear grinding faults, which is important for diagnostics/root-cause analysis purposes.

First, we re-examine existing deep-learning approaches for this problem and identify hidden flaws from a thorough root-cause analysis.

While useful in diverse tasks such as user behavior analytics, operational event processing, and root-cause analysis, today’s explanation engines are designed as stand-alone data processing tools that do not interoperate with traditional, SQL-based analytics workflows; this limits the applicability and extensibility of these engines.

These include the adoption of well-known tracing-related tools and standards in ES systems, with the respective advantages for root-cause analysis, anomaly detection, profiling and others.

One can perform manual root-cause analysis on telemetry data collected by HPC monitoring infrastructures to analyze performance variations.

OBJECTIVES Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate.

Results show that RCM can be achieved, elimination of more costly unscheduled maintenance by 40%-70%, a decrease of labor cost by 10% to 25%, incorporation of root-cause analysis, RM reduction of emergencies by 0.

Therefore, this study proposes an adaptive fault detection and root-cause analysis scheme for complex industrial processes using moving window kernel principle component analysis (KPCA) and information geometric causal inference (IGCI).

Errors in prescribing correct medications are common, and a root-cause analysis has shown common themes such as inadequate knowledge of the drug or the patient, failure to select appropriate drug dosages, and lack of knowledge of relevant rules such as dose adjustment in renal failure.

PURPOSE/OBJECTIVE(S) The purpose of this study is to present the root-cause analysis on failed patient-specific quality assurance (QA) measurements of pencil-beam-scanning (PBS) protons; referred to as PBS-QA measurement.

Further, the other problem-solving techniques, such as standardized work, plan–do–check–act cycle, root-cause analysis, Ishikawa diagram, and Why-Why (5-Why) analysis are also explained.

Here, it is essentially to mention that (simplified) customer environment/machine was also part of detailed 1D numerical model – customer engagement in root-cause analysis is important.

OBJECTIVE To perform a retrospective root-cause analysis of postoperative death after CRSx and HIPEC procedures.

This enables root-cause analysis of the pattern defects, and provides a foundation towards a better process monitoring solution.

Causal explanations of key events in a time-series have applications in design debugging, anomaly detection, planning, root-cause analysis and many more.

We examine in depth how the framework supports a detailed root-cause analysis of a well-known collection of event log imperfection patterns.

Manual root-cause analysis of performance variation based on system telemetry has become an increasingly time-intensive process as it relies on human experts and the size of telemetry data has grown.

Their localization is facilitated through a root-cause analysis, which is also based on the model description of the plant.

Causal explanations of key events in a time-series has applications in design debugging, anomaly detection, planning, root-cause analysis and many more.

Using existing root-cause analysis processes, the authors developed and implemented a framework designed to identify the causes of student failure in clinical education.

Urgently needed are: (i) an aligned and fully validated sample preparation strategy tested on a range of different food matrices; (ii) a confirmation of positive flame ionisation detection (FID) results by confirmatory methods such as mass spectrometry – in line with the CEN Standard and the Joint Research Centre (JRC) Guidance Document, (iii) a more detailed root-cause analysis in the reports of laboratories through the use of mineral oil markers, and (iv) a fully validated official method for the concerned foods with a limit of application <10 mg/kg food.

Root-cause analysis (RCA) for service performance degradation can be a challenging exercise given the increasingly complex, inter-related, distributed infrastructure environment in today’s enterprises.

Four themes were identified within the literature: the adverse emotional influence of complications (anxiety, guilt, sadness, shame, interference with professional and leisure activities) after intraoperative adverse events; coping mechanisms used by surgeons and trainees (limited discussion with colleagues, exercise, artistic or creative outlets, alcohol and substance abuse); institutional support mechanisms and barriers to support (clinical conferences, discussion with mentors, a perception that emotional distress would be perceived as a constitutional weakness); and the consequences of complications in future clinical practice (changes in practice, introduction of protocols, education of staff members, and participating in root-cause analysis).

This root-cause analysis is summarised in this paper as is the retuning that was undertaken on the estimation and control system parameters to improve disturbance prediction and rejection within the existing ADCS architecture.

Accurate detection and root-cause analysis of oscillations is of great interest for the economic viability of the process operation.

Further, a postprocessing workflow is developed to stitch together adjacent scans measured in a serial fashion and expand the FOV of each individual sc-AFM such that total inspection area per cycle can be balanced with throughput to perform larger area inspection for uses such as defect root-cause analysis.

Common approaches to detecting suicide in the healthcare setting include the National Death Index (NDI) and Root-Cause Analysis (RCA) methodology.

To that end, we propose an innovative tool, named LADRA, for log-based abnormal tasks detection and root-cause analysis using Spark logs.

We propose an approach to automatically generate meaningful concolic test cases for this particular problem, and design and implement a provenance tracking mechanism to assist root-cause analysis in general.

Methods: A retrospective analysis was conducted on root-cause analysis (RCA) reports of suicide in veterans occurring within 3 months of discharge from a residential drug treatment program that were reported to a Veterans Affairs facility between 2001 and 2017.

A corresponding two-part root-cause analysis procedure was developed to determine the rail locations of error motion degradation as well as the most probable physical location of damage that causes the detected error motion changes.

Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis.

This involves incident reporting and root-cause analysis to identify adverse events and their causes.

This paper provides an empirical analysis of straggler root-cause within virtualized Cloud datacenters; we analyze two large-scale production systems to quantify the frequency and impact stragglers impose, and propose a method for conducting root-cause analysis.

NGS enables the analyses of multiple regions of a genome in a single reaction format and has been shown to be a cost-effective and efficient tool for root-cause analysis of disease and optimization of treatment.

The next 2 articles in the series will focus on root-cause analysis, selection of change ideas to improve care gaps, execution of the QI project using rapid-cycle testing and monitoring to sustain improvement over time.

It is widely accepted that root-cause analysis of electrical bugs is highly difficult which further elongates the time needed to fix them.

We initiated a departmental case review (DCR) method based on root-cause analysis methods in a high-volume multiorgan transplant center.

We present \sys, a declarative, unsupervised root-cause analysis engine that uses time series monitoring data from large complex systems such as data centres.

The developed digital twin was used for anomaly detection and reasoning in a semi-automated root-cause analysis (RCA) approach.

The evaluation using real web application datasets demonstrates that ?-Diagnosis can identify all the actual root-causes at runtime and significantly reduce the candidate problem space, outperforming other time-series distance based root-cause analysis algorithms.

This research presents the architecture of a collaborative troubleshooting platform to establish user trust by presenting practical scenarios of problem diagnosis using the technique of root-cause analysis in a high tech company in Silicon Valley.

In conducting a root-cause analysis of uncertainty in GHG accounting from beef production, this study makes a novel contribution to the literature surrounding uncertainty in livestock emissions modelling.