February 9, 2012 | Barb Carr

Root Cause Tip: Using Corrective Action Helper® to Meet The Joint Commission (TJC) Recommendations for Document Review

When healthcare professionals perform root cause analysis (RCA), they want to define “What” happened, “Why” it happened, and then how to “Fix” the problem. These three pieces are considered core pieces to a “Thorough and Credible” RCA as coined and defined by the TJC. The TapRooT® process meets and, quite honestly, exceeds these requirements in many ways. Today, I want to spend a little bit of time focusing on one of the ancillary questions raised on TJC’s matrix that deals with Document Searches.

The key to responding to findings with solid corrective actions is understanding the root cause from every angle. It requires an open mind, creativity and tools to aid the investigator in understanding how to fix both Human Performance and Equipment related issues. Within the TapRooT® process, we have what is called Corrective Action Helper®. This tool provides guidance for identifying “Generic” issues, provides ideas for fixing the Root Causes, as well as providing a ready-made list of References for each root cause. The list of references provides both general industry and healthcare related documents that the investigator should consider reading or referencing as part of the fix. This provides the investigator with documents to review and to answer the question, “Cite any books or journal articles that were considered in developing this analysis and action plan:” from page 5 of the matrix.

Here is an example of what is included in the Documents section in Corrective Action Helper® for just one of our root causes, “Arrangement/Placement.” (This has to do with the physical location of equipment, displays, and controls):


* ANSI/HFES 100-2007, Human Factors Engineering of Computer Workstations, (2007), published by The Human Factors Society.

* KODAK’s Ergonomic Design for People at Work, (2004) by Eastman Kodak Company, published by John Wiley & Sons, Hoboken, NJ.

* Handbook of Human Factors and Ergonomics, Third edition (2006), by G. Salvendy, ISBN 0-471-44917-2, published by John Wiley & Sons, New York.

* Industrial Ergonomics: A Practitioner’s Guide, (1985) by D. C. Alexander and B. M. Pulat, published by Industrial Engineering & Management Press, Atlanta, GA.

* Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2007) by Pascale Carayon, published by Eribaum, Mahwah, NJ.

* International Encyclopedia of Ergonomics and Human Factors, Second edition (2006), edited by Waldemar Karwowski, 3 volume set. ISBN 978-0415304306.

* Medical Error and Patient Safety: Human Factors in Medicine, (2007) by George and Barbara Peters, published by CRC.

* Medical Device and Equipment Design: Usability Engineering and Ergonomics, (1995) by Michael E. Wiklund, published by CRC.

With this kind of reference list directly available through our system, why would you use anything else to find root causes? Not only can you provide a thorough and credible RCA, you also have a ready-made list of documents and references for review.

Root Cause Analysis
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