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Info and Chapters
Decision Analysis for Healthcare Managers
Farrokh Alemi, PhD
David H. Gustafson, PhD

Chapter 7: Root-Cause Analysis
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Companion Items

Sample Rapid-Analysis Exercises
Ivena. J. examined root causes of rape on campus
David Pattie analyzed root causes of medication error
Learning Tools
Download slides on root-cause analysis
Listen to a narrated presentation on an introduction to root-causes
Watch an animated example on how to set up a root-cause model using Netica software
Watch an animated example on how to analyze a root-cause model using Netica software
Websites of Interest
Download Netica software
Investigation of eye splash and needle stick incidents from an HIV-positive donor on an intensive care unit using root-cause analysis
Root-cause analysis of an airway filter occlusion
List of articles on using failure mode and effect analysis
List of articles on incidence reporting in healthcare
List of articles on root-cause analysis
Joint Commission's role in patient safety
Williams, P. M. 2001. “Techniques for Root Cause Analysis.” Proceedings of Baylor University Medical Center 14 (2): 154–57
Additional Readings
Bagian, J. P., J. Gosbee, C. Z. Lee, L. Williams, S. D. McKnight, and D. M. Mannos. 2002. “The Veterans Affairs Root Cause Analysis System in Action.” Joint Commission Journal on Quality Improvement 28 (10): 531–45.
Boyer, M. M. 2001. “Root Cause Analysis in Perinatal Care: Health Care Professionals Creating Safer health Care Systems.” Journal of Perinatal and Neonatal Nursing 15 (1) 40–54.
Dunn D. 2003. “Incident Reports—Correcting Processes and Reducing Errors. AORN Journal 78 (2): 212, 214–6, 219–20. This article reviews how a systems approaches to investigating failures that cause errors. The article identifies the steps that guide managers in adapting an incident reporting system.
Fischoff, B., Slovic, P., and S. Lichtenstein, S. 1978. "Fault Trees: Sensitivity of Estimated Failure Probabilities to Problem Representation." Journal of Experimental Psychology: Human Perception and Performance 4:330–34. This article shows how expert mechanics are influenced by the fault tree for why a car will not start up. The paper shows how experts many put more faith in an analysis than is justified.
Spath, P. L. 2003. “Using Failure Mode and Effects Analysis to Improve Patient Safety.” AORN Journal 78 (1): 16–37. This article introduces the concept of failure mode and effects analysis (FMEA) or prospective risk analysis and its utility in evaluating system safety in order to improve the safety of patient care activities. The article reviews the steps in the FMEA process.
Vincent, C. 2003. “Patient Safety: Understanding and Responding to Adverse Events.” New England Journal of Medicine 348 (11): 1051–56. This article is an excellent overview of the use of root-cause analysis in healthcare. The article provides a blue print regarding how to organize investigative teams.
Wald, H., and K. G. Shojania. 2001. “Chapter 5: Root Cause Analysis.” In Making Health Care Safer: A Critical Analysis of Patient Safety Practices, edited by A. J. Markowitz and R. M. Wachter. Washington, DC: Agency for Healthcare Research and Quality.