General questions Part 1
What is Root Cause Analysis
Root cause analysis (RCA) is:
an error analysis tool
a structured method used to investigate incidents and near hits
a retrospective method for detecting and describing safety or risk hazards
Who is in charge of the corrective action Tracking log?
Health and Safety Coordinator
What is the critical shift moving towards?
From Person Focused to System Focused
What are some examples to verify the effectiveness of a incident?
Observation
Documentation Review
Worker feedback
Follow up inspection/ Audit
Incident review
Performance Monitoring
Why do we use root cause analysis?
We use RCA to:
identify underlying problems that increase the likelihood of incidents,
RCA looks beyond human errors and identifies system issues.
avoid the trap of simply focusing on mistakes of individuals by identifying
active errors that can result due to the interaction between humans and complex systems, and
underlying errors that are hidden within systems that can contribute to potential adverse events.
What is the Purpose of Incident Reporting
The purpose of the Incident Reporting System (IRS) is to establish the requirements for incident reporting and analysis across the organization.
What are the two areas of improvement that was identified by the audit?
1. Making sure we're getting to the system root cause.
2. Making sure our corrective actions are properly tracked and verified.
What are the the first three steps in the complete process
1. Incident
2. Investigate
3. Identify contributing factors
Give examples of person focused thinking
1. Worker forget
2. Worker made a mistake
3.Worker wasn't careful
4. worker used poor judgement
5. Worker didn't follow procedure
6 Worker wasn't careful
What are some System focused questions to ask when doing a RCA ?
Was there:
• a clear procedure?
• appropriate training?
• adequate communication?
• effective supervision?
• appropriate equipment?
• a hazard assessment?
• a process that supported safe work?
• a clear expectation?
• a system for identifying and controlling the hazard?
How many "Why's" do we generally ask?
5
Corrective Actions =?
CHANGE
Define corrective actions
Corrective actions are the things we do to address a problem, and stop the same issue from happening again. They involve finding the root cause, fixing the mistake from reoccuring
Finish this ......The corrective action plan must be:
1. clearly defined
2. achievable
3. timebound
4. Assigned to specific workers to complete
Where can the Worker Incident Report Form be found?
On the T drive
What are the three elements of the corrective action plan?
The corrective action must be:
Clearly defined
Achievable
Timebound
Where can the investigation & communication checklist be found? and identify the exact location path
On the T drive
All Staff/Forms/ LFS Health & Safety/Investigation & Communication
Finish this " Accountability and ....?
Authority
what is the ULTIMATE goal of RCA?
is to prevent future harm by eliminating the underlying errors or system problems – prevention rather than cure.
What are some examples of system focused thinking?
Why was the mistake possible?
Why did the process allow it to be missed?
Was the procedure clear and practical?
What information influenced the decision?
What controls were in place?
What can we change to prevent recurrence?