Spotlight:
Peri-FACTS®
An eJournal for Lifelong
Learning in Obstetrics
From the University of Rochester's
Department of Obstetrics and Gynecology

Are All Root Cause Analysis (RCA)
Approaches Created Equal?
By Robert J. Latino
CEO, Reliability Center, Inc.
Hopewell, Virginia

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Learning Objectives for Peri-FACTS® Case #968: Upon
completion, the learner will be able to:
• Distinguish between analytical processes and tools for conducting root cause analyses (RCA).
• List the five basic steps to any investigation.
• Compare the results of the 5-Whys Approach, Fishbone Diagram, and Logic Tree when used on    the same case study.
• Describe the value of a broad and comprehensive RCA as opposed to using less stringent    approaches due to time pressures or meeting minimal regulatory compliance requirements.

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Patient Safety & Quality Healthcare Magazine
November / December 2011
MRI Safety 10 Years Later
What can we learn from the accident that killed Michael Colombini?
By Tobias Gilk, M.Arch. HSDQ, and Robert J. Latino

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In the summer of 2001, the radiology world was shocked to learn of an accident at Westchester Medical Center in New York state in which 6-year-old Michael Colombini was killed while being prepared for an MRI exam. Sedated and positioned in the scanner, the child's oxygen saturation levels began dropping quickly. After the piped-in oxygen serving the MRI scanner room malfunctioned, the anesthesiologist attending the child called for oxygen. A nurse, who was not part of the MRI department staff, responded to the anesthesiologist's calls and, meeting the anesthesiologist at the door to the MRI scanner room, handed him a steel oxygen tank. When the oxygen tank was brought into the MRI scanner room, the profound magnetic strength of the MRI scanner drew it out of the anesthesiologist's hands and into the scanner, where it struck and killed the young boy.

Nearly all practitioners who have some responsibility for safety in MRI—risk managers, technologists, compliance officers, administrators, patient safety officers, and radiologists—are aware of this most infamous MRI accident: the 2001 death of Michael Colombini. Ten years after this tragedy, it is appropriate to measure what we know about it, how that knowledge has reshaped MRI safety, and how improvements in MRI safety measure up. When we speak about MRI safety to medical professionals at conferences, we sometimes ask members of the audience what they know about the Colombini tragedy. Typically they can recount only three or four superficial facts about the accident:
1. The accident involved an oxygen cylinder drawn into the MRI scanner.
2. The oxygen cylinder struck and killed the boy, who was in the MRI scanner.
3. The oxygen cylinder was introduced to the MRI suite by a nurse or anesthesiologist.
4. The hospital where this occurred is located in New York.

Published HCPro Articles Written By:Robert J. Latino, CEO Reliability Center, Inc.

Defining and reducing human error:
The term "human error" is often used very loosely. We assume that when we use it, everyone will understand what it means. But that understanding may not be the same as what the person meant in using the term. For this reason, without a universally accepted definition, use of such terms is subject to misinterpretation.

Where do FMEA and RCA opportunities fit in the budget?
Where do proactive technologies such as root cause analysis (RCA) and Failure Modes and Effects Analysis (FMEA) stand when it comes to budget time?

The cost and truths of human error:
Some accidents that occur that do not rise to the level of a fatality. Sometimes such incidents result in degrees of financial loss, and sometimes they result in degrees of risk.

Contributors to human error and how to lower rates of committing error:
What does it take to complete a task error-free? This seems like an easy question to answer, yet its roots can be as complex as human beings themselves.

The supervisor's role in lowering human error:Discusses where a manager fits in when lowering human error. The key role of a supervisor is to provide leadership to those whom he or she manages. Part One.

The supervisor's role in reducing human error:Many of the issues regarding the supervisor's role in limiting human error will be related to the training of the work force. Let's look at what is involved with ensuring that we have a qualified and consistent work force. Part Two

In-field supervision can reduce error rates:Discusses the advantages of supervision oversight in the field and its effect on human error rates.

The effects of distractions on human performance:
Discusses the effect of distractions in the work force, as well as sleep-related problems and how to manage them.

Distractive environments: Mitigating complacency:
Discusses the internal and external factors affecting complacency in the workplace and its effect on human error. During our employment, when do we become comfortable to the point at which our complacency becomes dangerous?

RCI Analysis and Business Cases:

Analysis Reports: Using the LEAP Module of PROACT Enterprise Risk Management System

Basic FMEA Analysis - OB Ultrasound PRINCIPAL ANALYST: Bob Latino TEAM MEMBERS John Smith, Tom Brown, Jane Jones, Bill Williams The Reader will learn Defining the system to analyze - where the process begins & ends, terminal objective and criteria Discovery of probabilistic events Taking probabilistic events to the next level of discovering the most critical events to the system Using LEAP Module to delineate which events to justify a detailed RCA Download PDF   [OA] Opportunity Analysis - OB Ultrasound PRINCIPAL ANALYST: Bob Latino Opportunity Analysis (OA) was conducted to help us determine the most significant events in this facility that would require a thorough and credible Root Cause Analysis (RCA). This technique was modified from its traditional format to accommodate other processes and systems. The Reader Will Learn Determining the scope of the analysis Defining the Team Charter ( Terminal Objective) Identifying and recommending to management for further Root Cause Analysis (RCA) Define the term Frequency - and rate scale for the facility Define "Loss" as it pertains to the "system" being analyzed Begin a "Flow Diagram" - Mapping out the sub-systems of the process's chosen for analyses Conclusions and Recommendations Download PDF

PROACT® ERM Root Cause Analysis [RCA]- Cephalasporin Allergic Reaction PRINCIPAL ANALYST: Bob Latino The Reader will learn: How RCA was conducted to determine the "true" root causes of the event analyzed The PROACT Process Description - Using the Acronyms [5 Steps] to define the collective How PROACT ERM techniques replicates tasks involved in any investigative occupation. Logic Tree use for graphically expressing the "cause-and-effect" relationships Drilling down level to level specifically representing the "undesirable outcomes" that did occur Collecting just the "Facts" of occurrence and hypothetically asking "How Could" using the 5Ps. Download PDF

Business Cases and Cost / Benefit Analyses:

PROACT® Enterprise Risk Management used for seeing the cost / Benefits of performing an analysis. [RCA] The Reader will learn: Comparing the benefits of using a automated knowledge management system for RCA Inefficiencies of using a manual approach as found by the client The outcome of sources and assumptions on a manual versus automated applications Conclusions: reducing the cycle time of the average manual analysis by 90% Achieving an annual savings of $1,260,000. Reduction of equivalent consumed analysis resources [personnel] by 90% Download PDF

LEAP™ Analysis: Blood Drawing Process - Opportunity Analysis [OA] The Reader will learn: The following Opportunity Analysis (OA) was conducted to help us determine the most significant events in our facility that would require a thorough and credible Root Cause Analysis (RCA). This technique was modified from its traditional format to accommodate other processes and systems. The analysis was intended to look at either probabilistic and/or historical events. The analysis delineated which events were most critical to the system, or the most costly, in an effort to justify a detailed RCA. Download PDF