RCA & FMEA
2011.02
FMEAChart reviewChecklistClinical path
QCC5SPDCARCABSC Failure Mode Effect Analysis
Root Cause Analysis
Root Cause Analysis
-.
-
Reasons Swiss Cheese Model
RCA
RCA21
RCA-What
--Why
--How
-Action
SAC Severity Assessment Code
1 1 2 3 3
1 1 2 3 4
1-2 1 2 2 3 4
2-5 1 2 3 4 4
5 2 3 3 4 4
1.2
RCA 3.4
Report
RCA
1
2~~
3
SHELL Model
SHELL Model
Hardware
Software Environment
LivewareL
LS
H
E
Ssoftware
Hhardware
Eenvironment
Lliveware
4
Tabular Timeline
5 RCA
Why TreeBrainstorming
6
Fishbone Diagram
7
8
Tabular Timeline
95.4.18
1000
95.4.19
1000
95.4.21
1000
95.4.22
A
Maxtam
maxtam
130 50
UD
maxtam 130
A
maxtam
.
9
10
11
12
13
14
15
16
17PDCA
18
19
20
21
Why Tree
x
SOP
WHY
WHY
WHY
3-5 Why
Why tree analysis
Healthcare Failure Mode & Effect Analysis
:99.05.12FMEA
(FMEA)
FMEA1950(Grumman)FMEA
1963NASAFMEA
1970FMEA2002JCAHOFMEAFMEA
962.9.1.1~AFMEA (100?!)
FMEA
HFMEA1
*HFMEA*
HFMEA2
HFMEA
HFMEA
HFMEA3
1.2.3
HFMEA4
(1)
1A( )
1A( )
1B.1B.
1C.
1C.
1A11A21A31A41A51A61B11B21B31B41C11C2
1A11A21A31A41A51A61B11B21B31B41C11C2
(2)2A.check
2A.check
2B.
2B.
2C.
2C.
2A1check2A22B12B2
2C1
2C22C32C4clot2C52C62C72C8
2A1check2A22B12B2
2C12C22C32C4clot2C52C62C72C8
Risk Priority Number RPN
Sf-S-RPN= Sf S
HFMEA5
4 3 2 1
4 16 12 8 4
3 12 9 6 3
2 8 6 4 2
1 4 3 2 1
HFMEA6
HFMEAJosephetal(2002)
HFMEA(1)
1A
1A
1.
3 1 3 Y N Y N
3 1 3 Y N Y N
1A2
1.
3 2 6 Y N Y N
3 1 3 Y N Y N
HFMEA(2)
2B
2B1
1.
3 3 9 Y N N Y
2B2
1.
2 3 6 Y N Y N
2 4 8 Y N N Y
2B1
2B1
3A2
3B3
02468
1012141618 16.25
9.13
43.82%
RCAFMEARCA FMEA
RCA & FMEA Root Cause Analysis 4RCA21 SAC Severity Assessment Code RCASHELL Model 9 10 11 12Tabular Timeline 17 18 19 20 21 22 23 24 25 26Why tree analysis 28Healthcare Failure Mode & Effect Analysis(FMEA)FMEAFMEAHFMEA1HFMEA2HFMEA3HFMEA4(1)(2) 39HFMEA6 42HFMEA(1)HFMEA(2)RCAFMEA