What Additional Items Need to Be Considered in Doing a Root Cause Analysis?
Three additional issues need to be considered when doing a root cause analysis. The first is individual error. Errors by individuals should be initially considered as a special cause variation that leads to the discovery of common causes. Few persons come to work and decide that this is the day they will make a mistake. The technician who selects the wrong disinfectant does not stand there with two types of disinfectants in hand and consciously picks the wrong one. Individual errors are most likely the result of common cause variation of the system and its processes. Those processes most likely are hiring, competency review, continuing education to update staff, supervision of staff to measure their performance, communication and accessibility of the information, and design of processes in the work area. Management is responsible for designing processes to control causes that persons cannot control for themselves. In systems, examples of these causes are purchasing practices and proced
