Pediatric Informatics: Computer Applications in Child Health (Health ...

372 M. Apkon
Each effect is the consequence of at least one cause and one condition that allows or
predisposes the effect to occur. In the example above, the nurse selection the wrong
drug cassette was a causative action leading to the ultimate effect of administering
the wrong drug concentration whereas the fact that the patient’s order had expired
and the fact that the dispensing device had two different drug concentrations were
both contributing conditions that allowed an incorrect selection to be made. These
cause/condition and effect relations form an infinite chain that can be examined
as far back as one wants. However, once the causes and conditions become trivial
or beyond control, there is little value of pursuing further. The Five-Why’s work
backwards along that chain.
Whereas the Five-Why approach to conducting an RCA is relatively unstructured,
a number of other approaches rely on more structured approaches to ensure that specific
areas of risk are interrogated to define contributors to failure. One example of a
structured approach is the use of cause and effect diagrams that enumerate contributors
to failure from a set of prespecified domains. These diagrams are called Ishikawa
diagrams after one of quality management’s founding fathers, Kaoru Ishikawa. They
are also called “fishbone” diagrams because of their resemblance to a fish’s skeleton.
Key domains are shown as lines off the arrow leading to the specific problem.
Potential causes are shown as branches of these key domain lines and the contributors
to these causes are shown as braches from these branches. Key domains for consideration
often follow the mnemonic, “5M’s and a P” for: measurements, machines,
materials, methods, mother-nature (the environment) and people. The application of
this tool to the example above might identify the contributors (List 29.1, Fig. 29.2).
Mother-nature
Noisy environment
Correct cassette
not available
Units of measure
are based on
volume not dose
Fig. 29.2 Cause-effect diagram
Measurements People
IV Pump
doesn’t detect
formula
No second nurse
available to double
check
Incomplete training
Reordering waits
until empty
Materials Machines Methods
Narcotic Overdose