Criteria for the prioritization of hypotheses in root cause analysis

Explanatory hypotheses are formed and evaluated in root cause analysis. However, prior to investigation, the hypotheses must be prioritized. Often, methods such as nominal group technique, multi-voting, and simple voting are used to decide which to investigate first. This research seeks to provide concrete criteria for the prioritization of hypotheses using three levels of prioritization based on the strength of the available evidence. A quality leadership email distribution list was used to distribute a survey to quality departments. Respondents were asked to rate various scenarios as confirmed, strong, moderate, and weak evidence towards supporting a hypothesis. Only 2 of 13 scenarios did not have statistically significant results and these results can be used by quality departments to prioritize hypotheses to investigate during root cause analysis.     

Systematic root cause analysis of adverse drug events in a tertiary referral hospital

BACKGROUND: Adverse drug events (ADEs) occur frequently, and serious ADEs are associated with mortality or prolonged morbidity. As many ADEs are preventable, identification and modification of systems and processes that permit ADEs has the potential to reduce the rate of ADEs. METHODS: Root cause analysis was systematically employed in a blame-free fashion to investigate the patterns of serious ADEs that occurred during a 29-month period at Hermann Hospital (Houston), and process improvements were implemented on the basis of these findings. The consistently nonpunitive responses to the results of the initial and subsequent root cause analyses was gradually seen, accepted, and ultimately embraced by the hospital staff. RESULTS: The most commonly identified root causes were environmental factors (for example, increased census, increased acuity, change of shift) and staffing issues (for example, personnel new to a unit). Policy changes that led to increased use of forcing or constraining functions (for example, removal of concentrated intravenous potassium solutions from floor stocks) and better personnel support (for example, early awareness and response to localized increases in census and acuity) were particularly effective. Although limited by our lack of active surveillance and not necessarily directly due to the process changes that we implemented, the rate of voluntarily reported serious ADEs/100,000 patient days decreased during this time from 7.2 to 4.0, a decline of 45% (p < 0.001). CONCLUSION: Systematic application of root cause analysis followed by implementation of process changes that target the underlying cause(s) of each event can be successfully implemented in a large hospital.     

Using root cause analysis to address patient satisfaction and other improvement opportunities

BACKGROUND: Despite the considerable attention that health care organizations are devoting to the measurement of patient satisfaction, there is often confusion about how to systematically use these data to improve an organization's performance. A model to use in applying traditional quality improvement methods and tools to patient satisfaction problems includes five primary steps: (1) identifying opportunities, (2) prioritizing opportunities, (3) conducting root cause analysis, (4) designing and testing potential solutions, and (5) implementing the proposed solution. PATIENT SATISFACTION SURVEYS: A satisfaction survey serves best as a high-level screening device, not as a tool to provide highly detailed information about the root causes of patient dissatisfaction. The primary purpose of the survey in the model is to identify improvement opportunities and areas of significant improvement or deterioration. Secondary tools such as brief patient interviews or focus groups may better serve to probe intensively into the problem areas identified by the survey. These tools allow for a direct dialog with the patient to uncover root causes of dissatisfaction and establish potential solutions. DISCUSSION: Although the primary focus of this model has been patient satisfaction issues, the basic steps could easily be applied to virtually any improvement opportunity. Improvement teams should commit to a schedule of 90-minute weekly meetings for 7 weeks. The model, a simple translation of traditional improvement methods and tools to address the unique issues facing patient satisfaction improvement teams, can save improvement teams considerable time, resources, and frustration as they design and launch initiatives to improve patient satisfaction.     

宝钢2RH拉瓦尔喷嘴腐蚀失效原因分析

针对宝钢2RH拉瓦尔喷嘴腐蚀失效,分析了喷嘴的化学成分和金相组织,以及CO2对喷嘴的腐蚀机理,分析结果表明,喷嘴的选材不当和真空系统的废气腐蚀冲刷是主要原因,根据工况条件选用了新的材料并采取了相应的措施.     

某集中式空调水系统故障与原因分析

介绍集中式空调系统风冷式冷(热)水机组由于水系统维护问题导致的报警故障,并以某风冷螺杆式冷(热)水机组热回收器中换热铜管腐蚀泄漏故障为案例,通过对换热铜管的腐蚀处进行电子显微镜分析和化学分析以及水质检测,发现由于水系统水流量不足造成系统内部低压,外界空气通过排气阀进入热回收器,最终水中溶解氧含量超标导致热回收器中铜管腐蚀,指出必须重视集中式空调水系统的维护。     

Comparing the Fried frailty phenotype versus the Veterans Affairs frailty index among dialysis dependent patients

Introduction

Frailty in dialysis patients is a modifiable disease state which can increase mortality if left untreated but remains underdiagnosed as frailty evaluations can be arduous or time consuming. We evaluate the agreement between a clinical frailty construct (Fried frailty phenotype, FFP) against and an electronic health record-based Veterans Affairs Frailty Index (VAFI) and their association with mortality.

Methods

A r etrospective cohort analysis of 764 participants from the ACTIVE/ADIPOSE study was performed. Frailty as measured by VAFI and FFP was obtained and Kappa statistic estimating concordance between the two scores were calculated. Differences in mortality risk were analyzed according to presence or absence of frailty.

Findings

When assessing agreement between the VAFI and FFP, the kappa statistic was 0.09 (95% confidence interval [CI] 0.02–0.16) suggesting a low level of agreement. Frailty was independently associated with higher mortality risk (hazards ratio [HR] 1.40–1.42 in fully adjusted models depending upon frailty construct). Discordantly frail patients by construct had a higher risk of mortality though this was not statistically significant after adjustment. However, concordantly frail patients had much higher mortality risk compared to concordantly nonfrail (adjusted HR 2.08, 95% CI 1.44–3.01).

Discussion

Poor agreement between constructs is likely reflective of the multifactorial definition of frailty. While further longitudinal studies are needed to determine if the VAFI would be beneficial in the reassessment of frailty, it may be beneficial as a cue for further frailty testing (e.g., with FFP) with the combination of multiple frail constructs providing improved prognostic information.     

John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center

BACKGROUND: After the Veterans Affairs Medical Center (VAMC) in Lexington, Kentucky, lost two major malpractice cases in the mid-1980s, leaders started taking a more proactive approach to identifying and investigating incidents that could result in litigation. An informal risk management team met regularly to discuss litigation-prone incidents. During one in-depth review, the team learned that a medication error had caused the patient's death. Although the family would probably never have found out, the team decided to honestly inform the family of exactly what had happened and assist in filing for any financial settlement that might be appropriate. This decision evolved into an organization wide full disclosure policy and procedure. DISCLOSURE POLICY AND PROCEDURE: The Lexington VAMC's policy on full disclosure includes informing patients and/or their families of adverse events known to have caused harm or injury to the patient as a result of medical error or negligence. The disclosure includes discussions of liability and also includes apology and discussion of remedy and compensation. RESULTS: Full disclosure is the right thing to do and the moral and ethical thing to do. Moreover, doing the right thing actually seems to have mitigated the financial repercussions of inevitable adverse events that result in injury to patients. As reported in 1999, Lexington VAMC was in the top quarter of medical centers for number of tort claims filed but was in the lowest quarter for malpractice payouts resulting from these torts.     

Indian Mutiny Veterans: The Tytlers

Abstract

Though we have not come across any photographic record of the Indian Mutiny as it took place, there are photographs of places closely connected with that cataclysmic occurrence, taken soon after. None could have made a better follow-up of the sites of the Mutiny than Robert Christopher Tytler and his wife, Harriet Christina. Both had first-hand knowledge of the events, in Delhi and in Lucknow.     

非平稳地震作用下MSCSS动力可靠度分析及优化

基于巨子型有控结构体系(Mega-sub controlled structure system,即MSCSS)的组装原理,从抗震设防的角度提出了"有区别的等可靠度优化准则"。采用Hilbert-Huang变换(HHT)法合成非平稳人工地震波,将基于概率密度演化理论的动力可靠度分析方法用于MSCSS,编制了MATLAB与SAP2000的接口程序,以所提出的优化准则对非平稳地震作用下MSCSS进行了尺寸优化,并比较了优化前后的结果。研究表明:对MSCSS进行优化是有必要的,MSCSS优化后的可靠度分布比优化前更为合理,且响应控制能力也得到了提高。     

Mediators in action: Organizing sociotechnical system change

To extend and deepen the roles of mediators in relation to sociotechnical change, this article first suggested an analytical approach which thereafter was used for analysing two cases illustrating two Swedish mediating organizations in different sectors at different time periods: the half state-/half industry funded Research Institute for Water and Air Protection, IVL, in the 1960s and 70s; and the Swedish Urban Network Association, SUNA, in the early years of the 21st century. We found that the associated sociotechnical systems changed through the actions of mediators and their organization of time-spatial specific settings. The mediator concept contributed to our understanding of these changes through a number of visible processes of translating rather than transferring specific knowledge, by functioning as a single entrance to knowledge, by supporting the selection processes, and sometimes by bridging knowledge in unforeseen ways. Overall, the mediating actors took on roles to promote the system and encouraged actors within the system to connect and develop both the system as such.     

Using the Baldrige management system framework in health care: the Veterans Health Administration experience

BACKGROUND: In 1998 the Veterans Health Administration (VHA) developed the Quality Achievement Recognition Grant, a competitive grant application open to all Veterans Integrated Service Networks (VISNs) within the VHA system and based on the Baldrige management framework. Eight of the 22 VISNs attended the educational programs and initiated the grant application process; 7 completed applications. Team award experts from VHA and external sources reviewed, scored, and wrote feedback reports to all applicants and conducted four site visits. IDENTIFICATION OF BEST PRACTICES AND RECOMMENDATIONS FOR FUTURE APPLICANTS: Each application was compared to examples of ideal applications to identify areas of excellence and areas for improvement. In general, the best applicants identified and described key processes and articulated the methods used to evaluate and improve processes. For example, they were able to identify the process used to incorporate key constituents into the strategy development process. One applicant developed a series of management advisory committees, the membership of which includes veterans' service organizations, academic affiliates, community members, and congressional delegates, which were tapped to develop a strategic plan. Leading applicants in the future are likely to be able to demonstrate evidence of deployment and constant review of the strategy and to emphasize the human resources plan into the strategic planning and deployment. CONCLUSIONS: The Baldrige management framework is a useful tool for identification of areas of achievement and areas for improvement within the VHA. Potential applicants for the award could benefit from ensuring coherence across the application, placing a greater emphasis on work systems, and incorporating more extensive analysis of market conditions.     

Common cause failure probabilities in standby safety system fault tree analysis with testing—scheme and timing dependencies

Modelling and quantification of common cause failures (CCFs) in redundant standby safety systems can be implemented by implicit or explicit fault tree techniques. Common cause event probabilities are derived for both methods for systems with time-related CCFs modelled by general multiple failure rates. The probabilities are determined so that the correct time-average risk can be obtained by a single computation. The impacts of test intervals and test staggering are included. Staggered testing is best with a certain extra-testing rule, although extra testing is not important for 1-out-of-n:G systems. An economic model provides insights into the impacts of various parameters: the optimal test interval increases with increasing redundancy and testing cost, and it decreases with increasing accident cost and initiating event rate. Staggered testing with extra tests allows for the longest optimal test intervals. A practical technique is outlined for incorporating assessment uncertainties in the estimation of multiple failure rates based on data from many plants or systems.     

Analysing semiconductor manufacturing big data for root cause detection of excursion for yield enhancement

With the shrinking feature size of integrated circuits driven by continuous technology migrations for wafer fabrication, the control of tightening critical dimensions is critical for yield enhancement, while physical failure analysis is increasingly difficult. In particular, the yield ramp up stage for implementing new technology node involves new production processes, unstable machine configurations, big data with multiple co-linearity and high dimensionality that can hardly rely on previous experience for detecting root causes. This research aims to propose a novel data-driven approach for Analysing semiconductor manufacturing big data for low yield (namely, excursions) diagnosis to detect process root causes for yield enhancement. The proposed approach has shown practical viability to efficiently detect possible root causes of excursion to reduce the trouble shooting time and improve the production yield effectively.     

光干涉型甲烷测定器产生光谱漂移的原因

甲烷测定器是煤矿企业安全生产必不可少的测定仪器，光干涉型甲烷测定器在使用过程中产生的“光谱漂移”问题，直接影响甲烷测定精度。该文解析其工作原理，罗列了光谱自动漂移的种种现象，分析其影响因素并对防止光谱漂移提出具体的措施。     

BOPET生产线产生气泡的原因分析

本文介绍了BOPET薄膜生产中,在熔体线中产生气泡的种类,和各种气泡产生的原N,及怎样减少或消除气泡的方法。     

Optimization of system reliability in the presence of common cause failures

The redundancy allocation problem is formulated with the objective of maximizing system reliability in the presence of common cause failures. These types of failures can be described as events that lead to simultaneous failure of multiple components due to a common cause. When common cause failures are considered, component failure times are not independent. This new problem formulation offers several distinct benefits compared to traditional formulations of the redundancy allocation problem. For some systems, recognition of common cause failure events is critical so that the overall system reliability estimation and associated design resembles the true system reliability behavior realistically. Since common cause failure events may vary from one system to another, three different interpretations of the reliability estimation problem are presented. This is the first time that mixing of components together with the inclusion of common cause failure events has been addressed in the redundancy allocation problem. Three non-linear optimization models are presented. Solutions to three different problem types are obtained. They support the position that consideration of common cause failures will lead to different and preferred “optimal” design strategies.     

纳米粒子气溶胶分析系统的建立

纳米粒子气溶胶分析系统对粒径测量的量值可溯源到标准粒子,可进行单分散、多分散样品的测量以及电子分级筛选。该文介绍纳米粒子气溶胶分析系统的基本原理、测量方法和系统组成,总结了所进行的实验研究。并展望了良好的应用前景。     

控制图自动分析系统

描述了一种控制图自动分析系统,该系统具有自动计算各统计量与控制界限、绘图以及根据国标GB/T4091-2001对控制图进行自动分析等功能.通过该系统的应用实例,证明其具有很强的实用性.