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Journal articles on the topic 'Root Couse Analysis (RCA)'

Author: Grafiati

Published: 4 June 2025

Last updated: 1 August 2025

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1

Lanida, Bella Putri, Tito Yustiawan, and Sylvy Medtasya Dzykryanka. "ROOT CAUSE ANALYSIS ON HOSPITAL STANDARDS AND JOINT COMMISSION INTERNATIONAL STANDARDS: A COMPARATIVE STUDY." Jurnal Administrasi Kesehatan Indonesia 7, no. 1 (2019): 18. http://dx.doi.org/10.20473/jaki.v7i1.2019.18-24.

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Background: Healthcare Associated Infections (HAIs) are infections that patients caught during medical treatment and health care. Prevention and control of infection will lead to patient safety, which ultimately has an impact on efficiency, management of health care facilities, and improvement of service quality. Infection can be controlled by identifying the causes. One method to achieve this goal is the Root Cause Analysis (RCA).Aim: This study aims to analyze the implementation of Root Couse Analysis (RCA) conducted by the Infection Prevention and Control Committee at the Mother and Child H

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Aboumrad, Maya, Julia Neily, and Bradley V. Watts. "Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes." Journal of Medical Education and Curricular Development 6 (January 2019): 238212051989427. http://dx.doi.org/10.1177/2382120519894270.

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Background: Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA). Objective: The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA’s Chief Resident in Quality and Safety program about RCA. We report the use of experiential learning to teach RCA, and clinicians’ preparedness to conduct and teach RCA post-training. We provide curriculum details and materials to be adapted for widespread

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Kwok, Yick-ting, and Alastair P. Mah. "Qualitative study on experience of healthcare staff who have undergone a hybrid root cause analysis training programme." BMJ Open Quality 12, no. 2 (2023): e002153. http://dx.doi.org/10.1136/bmjoq-2022-002153.

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BackgroundRoot cause analysis (RCA) is a structured investigation methodology aimed at identifying systems factors to prevent recurrence of incidents. To enhance staff’s knowledge and skills, a hybrid RCA training course was conducted in February 2021. Overseas instructors conducted training online and local participants attended the training together physically with onsite facilitator support. This study aimed at understanding the experiences of trainees who have undergone the training, evaluated its effectiveness and identified opportunities to enhance RCA training quality in the future.Meth

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Schall, Sarah E., Timothy L. Switaj, Ashley T. Parham, James K. Aden, and Renée I. Matos. "Creating Patient Safety Team Members Through a Simulation-Based Interprofessional Root Cause Analysis Course." Journal of Graduate Medical Education 14, no. 3 (2022): 304–10. http://dx.doi.org/10.4300/jgme-d-21-00712.1.

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ABSTRACT Background The Accreditation Council for Graduate Medical Education Common Program Requirements require residents to participate in real or simulated interprofessional patient safety activities. Root cause analysis (RCA) is widely used to respond to patient safety events; however, residents may lack knowledge about the process. Objective To improve clinicians' knowledge of the tools used to conduct an RCA and the science behind them, and to describe this course and discuss outcomes and feasibility. Methods A flipped classroom approach was used. Participants completed 5 hours of pre-co

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Romdhon, Abdul ghofar, Mohammad Ilham, Rini puji Astutik, and Denny Irawan. "Penanganan Lonjakan Vibrasi pada Rotor Elektrik Turbin di PLTU Gresik." Journal of Applied Smart Electrical Network and Systems 1, no. 02 (2020): 47–54. http://dx.doi.org/10.52158/jasens.v1i02.116.

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This analysis will discuss how to handle vibrations in the Turbine Rotor. The measuring instrument used is Vibration Analysis test with Prov. 2140 type which measured amplitude, time and frequency domain of vibration signal. The results obtained in this study, firstly, the measurement vibration of rotor at PT PJB Gresik found the highest amplitude of vibration was 59,6 μm at 3000 rpm. In this condition, the rotor is in very good condition as per standard vibration in ISO 7919-2 stated 80 μm at 3000 rpm. However in the next measurement, there is an dramatically increase of amplitude in each vib

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Amrillah, Mohammad Suhud, Akhmad Wasiur Rizqi, and Moh Jufriyanto. "Risk Analysis of Work Accidents at CV. Sumber Rejeki Gresik with Failure Mode and Effect Analysis (FMEA) and Root Cause Analysis (RCA) Methods." MOTIVECTION : Journal of Mechanical, Electrical and Industrial Engineering 6, no. 2 (2024): 191–204. http://dx.doi.org/10.46574/motivection.v6i2.324.

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In the current industrial era, Occupational Safety and Health (OHS) is something that needs to be considered. Increasing awareness of OHS in every employee will have a very good impact both in terms of material and non-material. If this is ignored, it will be fatal and of course can cause losses. The accident data totaled 6 times which was calculated from January 2022 to November 2022 with a total of 9 employees. The number of accidents that occurred is still said to be very high with a percentage of 54% of the total workforce. this is not the same as government policies that implement zero ac

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Ajeng Sekarkirana Pramesti Kameswara, Denie Amanda Octavia, Rr Nurul Rahmanita, Nico Resando Nainggolan, Muhammad Fajar Nur Iman, and Erfa Fatoni Dwi Putra. "Corrective and preventive actions for damage product problem on raw materials for the pharmaceutical industry." JENIUS : Jurnal Terapan Teknik Industri 4, no. 1 (2023): 1–11. http://dx.doi.org/10.37373/jenius.v4i1.381.

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One issue that plagues every industry is defective products, which is an unintended product quality deviation during the production process. In a pharmaceutical business situated in East Jakarta, Indonesia's Raya Bogor Street, data shows that when products were received from vendors, almost 30% of imported raw materials for Pharma X were damaged or defective. We apply the root cause analysis (RCA) method on faulty or damaged items to identify the fundamental issues that arise, and we offer solutions for preventive and corrective activities. As a result, the supplier is to blame for any damage

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Choi, Eun-Young, Mi-Jeong Kwak, Jeong-Hae Hwang, Seung-Eun Lee, Won Lee, and Minsu Ock. "Truths and Misconceptions in Root Cause Analysis." Quality Improvement in Health Care 29, no. 1 (2023): 70–84. http://dx.doi.org/10.14371/qih.2023.29.1.70.

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We introduced guidelines, cases, and educational materials that helped perform Root Cause Analysis (RCA), while suggesting the limitations of RCA and ways to overcome them to make it more active in the Republic of Korea. By arranging the existing major domestic and foreign literature on RCA, helpful information on RCA is provided to practitioners. RCA utilizes several tools to find an incident’s systematic cause rather than a single methodology. Depending on the institution, various guidelines for RCA are presented, and the RCA step suggested by The Joint Commission is often used. Moreover, va

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Dorner, Joe W., and Richard J. Cole. "Variability Among Peanut Subsamples Prepared for Aflatoxin Analysis with Four Mills." Journal of AOAC INTERNATIONAL 76, no. 5 (1993): 983–87. http://dx.doi.org/10.1093/jaoac/76.5.983.

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Abstract The variability in aflatoxin concentration among peanut subsamples ground with 4 different mills was evaluated. Twenty 2 kg samples of naturally contaminated peanuts were ground in a Dickens subsampling mill (DM), a Stephan model UM-12 vertical cutter mixer (SM), and a Robot Coupe model RSI6Y-1 vertical cutter mixer (RC1). Twenty 4 kg samples were ground in the DM, SM, and a Robot Coupe model R10P vertical cutter mixer (RC2). From each 2 kg sample, ten 100 g subsamples were withdrawn, and from each 4 kg sample, ten 200 g subsamples were withdrawn. Subsamples were analyzed for aflatoxi

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Groot, Wendy. "Root cause analysis – what do we know?" Maandblad Voor Accountancy en Bedrijfseconomie 95, no. 1/2 (2021): 87–93. http://dx.doi.org/10.5117/mab.95.60778.

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Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective

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Groot, Wendy. "Root cause analysis – what do we know?" Maandblad Voor Accountancy en Bedrijfseconomie 95, no. (1/2) (2021): 87–93. https://doi.org/10.5117/mab.95.60778.

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Root cause analysis (RCA) provides audit firms, regulators, policy makers and practitioners the opportunity to learn from past adverse events and prevent them from reoccurring in the future, leading to better audit quality. Recently approved regulations (ISQM1) make RCA mandatory for certain adverse events, making it essential to learn how to properly conduct an RCA. Building on the findings and recommendations from the RCA literature from other industries where RCA practice is more established such as the aviation and healthcare industries, audit firms can implement an adequate and effective

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Memon, Sajjan Iqbal, and Misbah Shakeel. "Does Root Cause Analysis improves patient safety?" Journal of Turkish Family Physician 15, no. 1 (2024): 44–47. http://dx.doi.org/10.15511/tjtfp.24.00144.

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This editorial letter discusses the important subject of root cause analysis (RCA) and how it might increase patient safety. To investigate adverse incidents and determine underlying causes and contributing factors, the letter highlights the importance of RCA as a methodical and comprehensive technique. Important information about the use of RCA in health care, its steps, and the possible effects on patient safety can be found in the references included in this letter. RCA identifies system failure reasons. It offers the information required to resolve failures and helps clinical risk managers

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Ramadhan, Dona. "ROOT CAUSE ANALYSIS USING FRAUD PENTAGON THEORY APPROACH (A CONCEPTUAL FRAMEWORK)." Asia Pacific Fraud Journal 5, no. 1 (2020): 118. http://dx.doi.org/10.21532/apfjournal.v5i1.142.

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Fraud and corruption are two types of crimes that can harm others. According to Transparency International, the perceived level ofpublic sector corruption in Indonesia was ranked 89 out of 180 countries in the world in 2018. Seeing this condition, more attention should be paid to the prevention and deterrence process to reduce the more losses. This study aims to develop a conceptual framework for fraud prevention and deterrence by developing root cause analysis using the pentagon fraud approach. Through a literature review, researcher tries to combine root cause analysis with fraud pentagon, c

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Amruta Mhatre, Afrid Shaikh. "LLM for Automated Root Cause Analysis in Microservices Architectures." Journal of Information Systems Engineering and Management 10, no. 13s (2025): 448–61. https://doi.org/10.52783/jisem.v10i13s.2100.

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The adoption of microservices architectures has introduced significant challenges in diagnosing and resolving system issues efficiently, as multiple services handling millions of requests generate vast volumes of exceptions, including business errors and critical runtime failures. Traditional manual approaches for error analysis and Root Cause Analysis (RCA) are time-consuming, error-prone and lack scalability. Existing tools often aggregate exceptions but fail to effectively classify or diagnose root causes, leading to prolonged system downtimes and reduced developer productivity. This resear

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Balakrishnan, Karthik, Michael J. Brenner, John W. Gosbee, and Cecelia E. Schmalbach. "Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)." Otolaryngology–Head and Neck Surgery 161, no. 6 (2019): 911–21. http://dx.doi.org/10.1177/0194599819878683.

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With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention i

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Researcher. "RISE OF AI-POWERED ROOT CAUSE ANALYSIS: REVOLUTIONIZING PROBLEM SOLVING IN MODERN SYSTEMS." International Journal of Computer Engineering and Technology (IJCET) 15, no. 4 (2024): 158–67. https://doi.org/10.5281/zenodo.13141499.

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This comprehensive article explores the transformative impact of AI-powered root cause analysis (RCA) across various industries. It delves into the core components and key technologies driving AI-powered RCA, including machine learning, anomaly detection, and natural language processing. The article compares traditional RCA methods with AI-driven approaches, highlighting AI's significant advantages in speed, accuracy, and scalability. It examines specific IT operations and manufacturing applications, demonstrating how AI-powered RCA is revolutionizing problem-solving and optimization in these

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Ko, Elena (You Jung), Charles M. Carpenter, David J. Gagnon, and Anne M. Andrle. "Pharmacist-Managed Inpatient Dofetilide Initiation Program: Description and Adherence Rate Post-Root Cause Analysis." Journal of Pharmacy Practice 33, no. 6 (2019): 784–89. http://dx.doi.org/10.1177/0897190019834130.

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The aim of this article is to describe the pharmacist-managed dofetilide initiation program at Maine Medical Center (MMC), assess the adherence rate to 8 core clinical metrics, and review adverse effects before and after a root cause analysis (RCA). Core clinical metrics included pharmacist note entered within 4 hours of dose administration, dose chosen correctly per renal function, QTc measurements obtained and reviewed 2 hours after each dose, appropriate dose adjustment per the most recent QTc measurement, documentation of patient education, and assessment of conduction abnormality, drug–dr

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Lee, Il Jae, A. Ran Lee, and Kyung-Sun Lee. "Accident Analysis Modeling and Case Study of Hydrogen Refueling Station Using Root Cause Analysis (RCA)." Safety 11, no. 2 (2025): 60. https://doi.org/10.3390/safety11020060.

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As the global transition to carbon neutrality accelerates, hydrogen energy has emerged as a key alternative to fossil fuels due to its potential to reduce carbon emissions. Many countries, including Korea, are constructing hydrogen refueling stations; however, safety concerns persist due to accidents caused by equipment failures and human errors. While various accident analysis models exist, the application of the root cause analysis (RCA) technique to hydrogen refueling station accidents remains largely unexplored. This study develops an RCA modeling map specifically for hydrogen refueling st

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Alifia, Redina Thara, and Inge Dhamanti. "IMPLEMENTATION OF ROOT CAUSE ANALYSIS ON PATIENT SAFETY IINCIDENCE IN HOSPITAL: LITERATURE REVIEW." Journal of Public Health Research and Community Health Development 6, no. 1 (2022): 14–20. http://dx.doi.org/10.20473/jphrecode.v6i1.31556.

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ABSTRACT Background: Root cause analysis (RCA) is a process used by hospitals to reduce the level of patient safety incidents. The minimized application of root cause analysis has resulted in inevitable patient safety incidents. Research objectives: This study aims to determine the application of RCA to patient safety incidents in hospitals. Method: The method used in this study was a literature review. Articles were obtained through the Pubmed, SAGE, and Google Scholar databases published in 2016-2021. Results: The implementation of RCA in 46 hospitals in France, the United States, and Hon

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Pattipeilohy, Riany, and Astrie Kusuma Dewi. "ROOT CAUSE PROBLEM SOLVING DENGAN METODE FAULT TREE ANALYSIS." Prosiding Seminar Nasional Teknologi Energi dan Mineral 3, no. 1 (2023): 695–703. http://dx.doi.org/10.53026/sntem.v3i1.1232.

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Unit Residue Catalityc Cracking (RCC) di desain untuk mengolah treated residue (DMAR) dari ARDHM dan Atmospheric Residue (AR) dari Crude Destillation Unit (CDU) dengan bantuan katalis. Proses pembakaran katalis memerlukan supply Air Instrument sebanyak 100% dari Main Air Blower (MAB) ke regenerator. Sebanyak 70% menuju ke upper regenerator sedangkan 30% ke lower regenerator. pada unit RCC permasalahan utamanya adalah terjadi cut off, Untuk menganalisa faktor-faktor penyebab terjadinya cut off di unit RCC menggunakan Root Couse Problem Solving (RCPS) sehingga ditemukan akar dari permasalahan ya

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Vlasenko, V. V., and D. A. Minochkin. "OVERVIEW OF ROOT CAUSE ANALYSIS MECHANISMS FOR TELECOMMUNICATION NETWORKS." Collection of scientific works of the Military Institute of Kyiv National Taras Shevchenko University, no. 83 (2024): 58–64. http://dx.doi.org/10.17721/2519-481x/2024/83-06.

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Telecommunication networks are an integral part of modern information society, providing data transmission and communication among millions of users worldwide. The complexity and scale of these networks are constantly growing, which increases the demands on their reliability and stability. One of the key tasks in ensuring the efficient operation of telecommunication networks is the identification and elimination of the root causes of failures and anomalies that can significantly affect the quality of service for end users. Root cause analysis (RCA) is a powerful tool for identifying the primar

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Renger, PhD, MEP, Ralph, Mary Davis, DrPH, and Brenda Granillo, MS. "Using root cause analysis (RCA) to facilitate corrective actions, after action reports (AARs), and improvement plans." Journal of Emergency Management 10, no. 6 (2018): 442. http://dx.doi.org/10.5055/jem.2012.0121.

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Root cause analysis (RCA) is methodology recommended by the Homeland Security Exercise and Evaluation Program (HSEEP) for examining why exercise objectives were not met and providing specific recommendations for corrective action. The consequence of not completing the RCA as required by HSEEP is significant. In the absence of a RCA arriving at the best corrective action is less likely. Despite its importance, there is research evidence from a Centers for Disease Control and Prevention study that the RCA is seldom completed. Several reasons are presented as to why the RCA is not completed inclu

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Quraishi, Sadeq A., Stephen J. Kimatian, W. Bosseau Murray, and Elizabeth H. Sinz. "High-Fidelity Simulation as an Experiential Model for Teaching Root Cause Analysis." Journal of Graduate Medical Education 3, no. 4 (2011): 529–34. http://dx.doi.org/10.4300/jgme-d-11-00229.1.

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Abstract Purpose The purpose of this study was to assess the effectiveness of high-fidelity simulation for teaching root cause analysis (RCA) in graduate medical education. Methods Thirty clinical anesthesiology-1 through clinical anesthesiology-3 residents were randomly assigned to 2 groups: group A participants received a 10-minute lecture on RCA and participated in a simulation exercise where a medical error occurs, and group B participants received the 10-minute lecture on RCA only. Participants completed baseline, postintervention, and 6-month follow-up assessments, and they were evaluate

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Erawati, Ni Kadek Erna, I. Made Ady Wirawan, and Cokorda Bagus Jaya Lesmana. "Incidence of dispensing errors before and after root cause analysis at Sanglah General Hospital, Denpasar." Public Health and Preventive Medicine Archive 7, no. 2 (2019): 110–13. http://dx.doi.org/10.53638/phpma.2019.v7.i2.p06.

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Background and purpose: Drug dispensing errors have a major impact on the incidence of medication errors, and can be very dangerous to patients and affect the quality of care. Root cause analysis (RCA) is an approach to prevent dispensing errors by identifying the root of the problem, make efforts to improve comprehensively across departments so that incidence of dispensing errors are not repeated. The purpose of this study is to determine the differences in the incidence of dispensing errors before and after the RCA. Methods: This is a descriptive study by calculating the incidence of dispens

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Middleton, Sandy, Carol Walker, and Rosemary Chester. "Implementing root cause analysis in an area health service: views of the participants." Australian Health Review 29, no. 4 (2005): 422. http://dx.doi.org/10.1071/ah050422.

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Purpose: This study identifies the attitudes of participants in the root cause analysis (RCA) process and barriers to it?s implementation within one New South Wales area health service. Method: Employees and consumer representatives of the former South Western Sydney Area Health Service who participated in an RCA as either a team member or a team leader between December 2002 and October 2003 completed a self-administered survey. Results: Thirty seven of 39 eligible participants completed the survey (response rate 95%). The respondents identified formulation of causal statements, ensuring the c

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Meyer, Oliver, Eric Johnson, and Jacob Brown. "A Unified Framework for Anomaly Detection and Root Cause Analysis in Microservice Systems." Computer Life 13, no. 2 (2025): 7–11. https://doi.org/10.54097/1gw77589.

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Modern software applications increasingly rely on microservice architectures for scalability, flexibility, and rapid deployment. However, this architectural paradigm introduces new complexities in monitoring system behavior, identifying anomalies, and determining their root causes across distributed services. Existing solutions often address anomaly detection and root cause analysis (RCA) in isolation, leading to fragmented insights and delayed resolution. This paper proposes a unified framework that integrates real-time anomaly detection with automated RCA using machine learning and graph-bas

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Groot, Wendy, Caroline Meertens, and Tom Winkelaar. "An empirical model for root cause analysis in the audit profession." Maandblad voor Accountancy en Bedrijfseconomie 99, no. 3 (2025): 155–61. https://doi.org/10.5117/mab.99.148806.

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Audit firms conduct root cause analysis (RCA) to learn from errors and enhance future processes. This study aims to improve the effectiveness of these efforts by introducing a root cause taxonomy that categorizes underlying causes and develops a common language within the audit profession. Developed empirically and validated with data from an audit firm in the Netherlands, spanning from 2021 to 2024, the taxonomy includes six categories: Strategy and policy; Systems and procedures; Knowledge and understanding; Time and capacity; Human factors; and Client matters. Our findings reveal that the r

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Erawati, Ni Kadek Erna, I. Made Ady Wirawan, and Cokorda Bagus Jaya Lesmana. "Incidence of dispensing errors before and after root cause analysis at Sanglah General Hospital, Denpasar." Public Health and Preventive Medicine Archive 7, no. 2 (2019): 110. http://dx.doi.org/10.15562/phpma.v7i2.213.

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Background and purpose: Drug dispensing errors have a major impact on the incidence of medication errors, and can be very dangerous to patients and affect the quality of care. Root cause analysis (RCA) is an approach to prevent dispensing errors by identifying the root of the problem, make efforts to improve comprehensively across departments so that incidence of dispensing errors are not repeated. The purpose of this study is to determine the differences in the incidence of dispensing errors before and after the RCA.Methods: This is a descriptive study by calculating the incidence of dispensi

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Sakthivel, Rasu. "Root Cause Analysis: Techniques and Best Practices - For Current product improvement which can be implemented in New product design." International Journal of Innovative Research in Engineering & Multidisciplinary Physical Sciences 8, no. 1 (2020): 1–8. https://doi.org/10.5281/zenodo.13995934.

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Root Cause Analysis (RCA) has become an effective tool used to look for and eradicate the fundamental causes of product and process deficiencies. More and more industries are focusing on aspects of quality and dependability, and in this respect, RCA serves a valuable function in ongoing process improvement initiatives where it is effectively used on existing products and more importantly on new product development. This research article analyzes the historically accepted forms of RCA, considers suggestions on how RCA can be executed optimally, and examines the application of the results of RCA

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Ismail, Hajar, and Dodie Tricahyono. "Strengthening Payment Gateway Business Models Using Root Cause Analysis and the Business Model." International Journal of Scientific and Management Research 07, no. 12 (2024): 80–91. https://doi.org/10.37502/ijsmr.2024.71206.

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The payment gateway industry in Indonesia is rapidly growing, with the Finpay Payment Gateway being a key product. However, its market share is only 4%, indicating ongoing issues and shortcomings. This study aims to explore these issues using Root Cause Analysis (RCA) and Business Model Canvas (BMC) approaches. The research is a descriptive qualitative study, using observation and interviews for data collection. Using a fishbone diagram approach, the study identifies the root cause of the problem using RCA. A Business Model Canvas (BMC) is then created using a Business Model Pivot (BMP) to det

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Widyastuti, Khoirunisa Wahyu. "Gambaran Risiko Bahaya Pada Area Engine Room KM Nggapulu Menggunakan Metode HIRADC dan Root Cause Analysis: Studi Kasus PT XYZ." ENVIRONMENTAL OCCUPATIONAL HEALTH AND SAFETY JOURNAL 5, no. 1 (2024): 28. https://doi.org/10.24853/eohjs.5.1.28-41.

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Penelitian ini bertujuan untuk mengidentifikasi risiko dan bahaya pada area kerja di engine room KM Nggapulu, serta menentukan pengendalian yang tepat menggunakan metode HIRADC dan Root Cause Analysis (RCA). Hasil penelitian menunjukkan bahwa terdapat 28 risiko yang teridentifikasi, di mana 8 risiko masuk kategori rendah dan 20 risiko masuk kategori tinggi. Pengendalian risiko dilakukan berdasarkan identifikasi akar masalah menggunakan metode RCA dengan pendekatan 5 Why's Analysis. Rekomendasi pengendalian yang diusulkan meliputi peningkatan pengawasan, penggunaan APD yang lebih tepat, dan pel

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A'yun, Aisya Qurratul, and Iriani. "Failure Mode and Effect Analysis (FMEA) and Root Cause Analysis (RCA) for Urea Fertilizer Production Risk Mitigation." Jurnal Manajemen Bisnis 11, no. 2 (2024): 933–45. http://dx.doi.org/10.33096/jmb.v11i2.817.

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The production of urea fertilizer is one of the most important processes in the agricultural industry, but it cannot be separated from various risks that can interfere with its smooth operation. This research aims to identify and mitigate the risks involved in urea fertilizer production using the Failure Mode and Effect Analysis (FMEA) and Root Cause Analysis (RCA) methods. The results show that some of the major risks in urea fertilizer production include equipment failure, raw material supply disruption, and operational errors. By applying FMEA and RCA, the company can identify the root caus

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Vivek, Ramakrishnan, and Oleksandr P. Krupskyi. "Exploring Synergy: Integrating Qualitative Research Methods with Root Cause Analysis for Holistic Problem Understanding." European Journal of Management Issues 32, no. 4 (2024): 259–71. https://doi.org/10.15421/192422.

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Purpose: This study aims to explore the integration of qualitative research methods with Root Cause Analysis (RCA) to enhance the understanding of complex problems by capturing both quantitative and qualitative data. By bridging technical analysis and human-centered insights, this research seeks to provide a comprehensive framework for effective problem-solving. Design/Method/Approach: A systematic literature review was conducted, focusing on academic articles, books, and reports that examine the use of RCA and qualitative research methods individually and in combination. The study categorizes

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BOLZHELARSKYI, Y., M. BEREZOVYI, and P. GOŁĘBIOWSKI. "APPLICATION OF ROOT CAUSE ANALYSIS TECHNIQUES FOR THE INVESTIGATION OF RAILWAY TRANSPORT INCIDENTS." Transport systems and transportation technologies, no. 29 (April 7, 2025): 38–46. https://doi.org/10.15802/tstt2025/325376.

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Purpose. Enhancing railway traffic safety in Ukraine by implementing root cause and intermediate cause identification techniques in the processes of internal and technical investigations, as well as in forensic expert practice for railway transport incidents (RTIs), as stipulated by EN standards adopted in Ukraine. Methods. The method of RTI mechanism construction, root cause analysis (RCA) techniques reflected in DSTU EN 62740:2022, as well as methods of analysis, comparison, and synthesis. Results. A comparison between the RTI mechanism construction method currently used in Ukraine for deter

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Martin-Delgado, Jimmy, Alba Martínez-García, Jesús María Aranaz, José L. Valencia-Martín, and José Joaquín Mira. "How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review." Medical Principles and Practice 29, no. 6 (2020): 524–31. http://dx.doi.org/10.1159/000508677.

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<b><i>Objectives:</i></b> The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). <b><i>Methods:</i></b> A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Method

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Anderson, Janet E., and Alison J. Watt. "Using Safety-II and resilient healthcare principles to learn from Never Events." International Journal for Quality in Health Care 32, no. 3 (2020): 196–203. http://dx.doi.org/10.1093/intqhc/mzaa009.

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Abstract Objectives Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events. Design Qualitative and quantitative retrospective analysis of RCA reports. Setting A large acute healthcare Trust in London. Participants None. Interventions None. Main outcome measure Quality of RCA reports, robustness of actions proposed. Results RCA reports had low-to-moderate effectiveness ratings and low res

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Diamond, Anastasia, Maya Gonczi, Lizzie Einarson, and Brooke Baldwin. "Back to Your “Roots”: 5 Best Practices for Performing Root Cause Analysis." Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care 12, no. 1 (2023): 191–93. http://dx.doi.org/10.1177/2327857923121043.

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Root cause analysis (RCA) is not always a straightforward process, and many human factors researchers struggle with executing RCA effectively and efficiently. For example, when conducting large, multi-site studies, the data points from participants quickly add up and begin to blur together. Then, during data analysis, notes that once made sense or are left unfinished now require additional time and effort to decode. This can require further video review or internal discussion to corroborate what happened and why, creating delays in analysis and reporting. This may lead to more questions which

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Nurul Amin, Muhamed Jamil Khan, Noor Syaffynas Yusoff, Ahmad Azim Pauzi, et al. "ROOT CAUSE ANALYSIS (RCA): ARE FAILURES CAUSED BY INADEQUATE MAINTENANCE?" Platform : A Journal of Engineering 5, no. 2 (2021): 42. http://dx.doi.org/10.61762/pajevol5iss2art14135.

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While wrong quality assurance and control during maintenance activity may affect failures of physical assets, it is not always true to associate the “lack” of maintenance or the perception of it to failure of physical assets or degradation of system reliability. This paper intends to methodically assess the contribution of lack of maintenance towards physical asset failures, degradation of system reliability, and whether it matters or not. By achieving the conclusion, operation and maintenance engineers and facility heads should be better positioned to not immediately link failures to lack of

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Poghosyan, Arnak, Ashot Harutyunyan, Naira Grigoryan, and Nicholas Kushmerick. "Incident Management for Explainable and Automated Root Cause Analysis in Cloud Data Centers ." JUCS - Journal of Universal Computer Science 27, no. (11) (2021): 1152–73. https://doi.org/10.3897/jucs.76608.

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Effective root cause analysis (RCA) of performance issues in modern cloud environ- ments remains a hard problem. Traditional RCA tracks complex issues by their signatures known as problem incidents. Common approaches to incident discovery rely mainly on expertise of users who define environment-specific set of alerts and >target detection of problems through their occurrence in the monitoring system. Adequately modeling of all possible problem patterns for nowadays extremely sophisticated data center applications is a very complex task. It may result in alert/event storms including large nu

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Arditya, Evryan Yoga, Budi Nur Siswanto, and Dudi Hendra Fachrudin. "Analysis of quality control issues in lakop sapu ijuk using Root Cause Analysis (RCA)." EQUILIBRIUM : Jurnal Ilmiah Ekonomi dan Pembelajarannya 11, no. 2 (2023): 126. http://dx.doi.org/10.25273/equilibrium.v11i2.17250.

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<p class="Abstract"><em>UD Cibinong Indah Plastik is engaged in the production of cleaning tools, but the proportion of defective lakop sapu ijuk production is 6.2% of the total production, whereas the company's set standard for defective products is 5%, resulting in financial losses. In this study, the Root Cause Analysis method was employed to identify the root causes and propose improvements. Through Fault Tree Analysis, it was found that the most significant root cause is the lack of maintenance and replacement of machines. The suggested solutions through the Process Decision P

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Permana, Muhammad Ilham, and Dzakiyah Widyaningrum. "Optimizing Workplace Safety: A Comprehensive Analysis Of Accident Risks Through FMEA And RCA Methods." Jurnal Sains dan Teknologi Industri 21, no. 1 (2023): 158. http://dx.doi.org/10.24014/sitekin.v21i1.26043.

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Occupational health and safety (OHS) is the key to the company's growth in modern industry. Awareness of OHS has a positive impact on employees financially and non-financially. Indifference to OHS can be fatal, causing harm. OHS includes the establishment of a safe work environment through various approaches. Work accident data at PT. XYZ reaches 36% of the workforce, not yet meeting the government's zero accident policy—workshop at PT. XYZ has 9 types of OHS Risk. This study will use an assessment method using the Failure Mode and Effect Analysis (FMEA) method. After identifying and assessing

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Nagyová, Anna, Hana Pačaiová, Anna Gobanová, and Renáta Turisová. "An Empirical Study of Root-Cause Analysis in Automotive Supplier Organisation." Quality Innovation Prosperity 23, no. 2 (2019): 34. http://dx.doi.org/10.12776/qip.v23i2.1243.

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<p><strong>Purpose: </strong>The paper aims to introduce the practical application of using Root-cause analysis (RCA) by chosen methods of continual improvement in solving non-conformity occurrence in an organisation operating in the automotive field.</p><p><strong>Methodology/Approach: </strong>The chosen tools of (RCA), which includes an extended version of 5W2H and 5Whys were applied. Both tools were systematically applied step by step in case of claim solving, which occurred in automotive production.</p><p><strong>Findings: </s

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Wallace, Danielle, Denise Cochran, Jennifer Michelle Duff, Julia Lee Close, Martina Cathryn Murphy, and Arpan Patel. "A multicentered academic medical center experience of a simulated root cause analysis (RCA) for hematology/oncology fellows." Journal of Clinical Oncology 38, no. 29_suppl (2020): 188. http://dx.doi.org/10.1200/jco.2020.38.29_suppl.188.

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188 Background: Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Specifically, the ACGME requires trainee participation in interprofessional clinical patient safety activities, such as root cause analyses. These can be challenging to incorporate into busy schedules and are intimidating to some trainees, but simulated RCAs are a novel way to assure trainees gain important patient safety skills. We report on a multicentered experience utilizing a simulated RCA educat

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Nur, Syamsuddin, and Ikhwansyah Isranuri. "ANALISA KEANDALAN MESIN SCREW PRESS BERDASARKAN IDENTIFIKASI KEGAGALAN FAILURE MODE AND EFFECT ANALYSIS DAN ROOT CAUSE ANALYSIS." DINAMIS 9, no. 2 (2021): 7. http://dx.doi.org/10.32734/dinamis.v9i2.8433.

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Mesin screw press pada pabrik kelapa sawit berfungsi untuk memisahkan minyak dari buah lunak dan mengepressnya untuk menghasilkan crude oil dan nut. Pada PT. Samudera Sawit Nabati memiliki mesin screw press yang sistem perawatannya kurang maksimal. Tujuan penelitian ini adalah untuk mengetahui nilai keandalan dari mesin screw press dengan metode Reliability Block Diagram (RBD) berdasarkan identifikasi kegagalan menggunakan Failure Mode and Effect Analysis (FMEA) dan Root Cause Analysis (RCA). Berdasarkan identifikasi kegagalan metode FMEA, didapat komponen kritis pada mesin screw press yaitu t

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Pratikno, Faishal Arham, Muhamad Imron Zamzani, and Noni Oktiana Setiowati. "Application of Root Conflict Analysis (RCA+) to Identify Contradiction in Manufacturing Process." G-Tech: Jurnal Teknologi Terapan 7, no. 2 (2023): 722–29. http://dx.doi.org/10.33379/gtech.v7i2.2448.

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The presence of defects is a sign that the level of quality is not good enough. In this paper, we will discuss root cause analysis in the manufacturing process. In addition to analyzing the root of the problem, there are usually conditions called contradictions. Contradiction means a condition in which positive and negative effect simultaneously occur at the same time. Therefore, the Root Conflict Analysis (RCA+) has been adopted to find the root cause of the problem and at the same time identify the contradictions. Implementation of this method is carried out on the drilling process of compos

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Khunlertkit, Adjhaporn, and Nichole Jantzi. "Using the SEIPS Framework to Reveal Hidden Factors That Can Complicate a Vaccine Documentation Process." Proceedings of the Human Factors and Ergonomics Society Annual Meeting 60, no. 1 (2016): 541–45. http://dx.doi.org/10.1177/1541931213601125.

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Health care organizations have deployed root cause analysis (RCA) method to identify trends and assess risks. RCA can be used whenever human error is suspected. An organization that appropriately takes a system approach when conducting an RCA, often discovers both active and latent errors that may be mitigated through system changes (e.g., policies and procedures). However, in many circumstances, the RCA is rushed, the process is not systematic, and only active errors are identified in a complex situation. In addition, the findings are oftentimes driven by hindsight bias, in which the true roo

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Mustofa, Arifuddin, Christ Rudianto, and Penidas Fiodinggo Tanaem. "Perancangan Sistem Informasi Perpustakaan SMA N 1 Tengaran Menggunakan ROOT CAUSE ANALYSIS (RCA)." JATISI (Jurnal Teknik Informatika dan Sistem Informasi) 9, no. 1 (2022): 137–49. http://dx.doi.org/10.35957/jatisi.v9i1.1470.

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Belum maksimalnya sekolah dalam pemanfaatan teknologi informasi membuat sekolah sedikit tertinggal dan kurang efektif dalam pelayanan peminjaman maupun pendataan buku, karena dalam pelayanan masih menggunakan sistem manual yaitu dengan menulis di buku peminjaman, sehingga dibutuhkan sistem informasi yang dapat membantu dalam pelayanan perpustakaan. Dalam perancangan sistem informasi perpustakaan digunakan metode analisis studi literatur, observasi, wawancara dan RCA (Root Cause Analysis) langsung kepada siswa dan petugas perpustakaan. RCA sendiri dipakai untuk pendekatan sebagai bahan analisis

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Aboumrad, Maya, Alexander Fuld, Christina Soncrant, Julia Neily, Douglas Paull, and Bradley V. Watts. "Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration." Journal of Oncology Practice 14, no. 9 (2018): e579-e590. http://dx.doi.org/10.1200/jop.18.00159.

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Purpose: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement. Methods: We searched the National Ce

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Satyadeepak Bollineni. "Systematic approach to root cause analysis in distributed data processing systems." World Journal of Advanced Research and Reviews 25, no. 2 (2025): 2343–50. https://doi.org/10.30574/wjarr.2025.25.2.0609.

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Distributed data processing is a powerful capability, but with it comes the challenge of ensuring the reliability and performance of the system often on a larger scale, it is especially important to systematically identify the root cause of failures and address them accordingly. Cloud computing has changed the game by introducing scale, flexibility and low-cost alternatives to big data processing. With distributed systems getting increasingly complex, diagnosing failures has become defeated due to many components relying on each other and as workloads change dynamically. This paper presents a

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Tescher, Ann, Michelle Deppisch, Cassendra Munro, Vince Jorgensen, and Janet Cuddigan. "Perioperative pressure injury prevention: National Pressure Injury Advisory Panel root cause analysis toolkit 3.0." Journal of Wound Care 31, Sup12 (2022): S4—S9. http://dx.doi.org/10.12968/jowc.2022.31.sup12.s4.

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Objectives: Operating room-related pressure injuries (ORPI) are particularly challenging to examine for several reasons. Time in the OR is often a distinct event within the hospitalisation, and discovery of an ORPI may occur between several hours and up to 5 days postoperatively. The National Pressure Injury Advisory Panel (NPIAP) first developed a root cause analysis (RCA) toolkit in 2017 as a systematic strategy for investigating the root causes of facility-acquired pressure injury (PI). The purpose of this 2021 RCA toolkit update was to address an expanded investigation of medical device-re

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