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Beyond root cause analysis: An enriched system oriented event analysis model for wide application
Author(s) -
Chuang Sheuwen,
Howley Peter P.
Publication year - 2012
Publication title -
systems engineering
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.474
H-Index - 50
eISSN - 1520-6858
pISSN - 1098-1241
DOI - 10.1002/sys.21246
Subject(s) - root cause analysis , root cause , event (particle physics) , computer science , root (linguistics) , process (computing) , key (lock) , systems engineering , software engineering , reliability engineering , engineering , programming language , computer security , linguistics , philosophy , physics , quantum mechanics
Abstract An elementary System Oriented Event Analysis (SOEA) model was developed as an innovative method addressing serious limitations of the traditional root cause analysis (RCA) in healthcare. The SOEA has three distinctive capabilities beyond RCA: multiple events analysis, systems thinking, risk control formulation and alignment. It was applicable to events arising within strict sequential processes. However, for wider application to nonsequential, network system flows, the model needed to be redesigned. The engineering concepts of verification and validation were adopted as guides for the redesign. Patient falls in three differently sized hospitals were used to verify the applicability of the redesigned model. The resulting enriched SOEA model (enSOEA) was later applied in a scabies outbreak case as a validation test of success. This paper aims to describe how the elementary SOEA model was redesigned to achieve the enriched SOEA that is applicable beyond the sequential process, and provides key lessons learned from the tests for promoting its application. ©2012 Wiley Periodicals, Inc. Syst Eng 16