RCA Example: Cause-and-Effect Diagram

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RCA Example: Cause-and-Effect Diagram

One of the tools that can be used when performing an RCA is the cause-and-effect diagram, which is often referred to as a "fishbone diagram" because of its appearance.
Cause-and-Effect (Fishbone) Diagram Example
This type of diagram graphically helps identify and organize known or possible causes for a specific problem or area of concern.
In this theoretical example, the identified problem is a "near miss." Two units of Red Blood Cells were taken to the Dialysis unit for transfusion of two different patients. The first unit was hung by one clinical person and started just as another clinical person noticed that the unit that he/she picked up for transfusing another patient had the wrong identifying information. The blood was stopped immediately on the first patient.
Some of the benefits of constructing a "fishbone diagram" are that it
  • Helps determine root causes using a structured approach.
  • Encourages group participation and utilizes group knowledge.
  • Indicates possible variations in a process.
  • Indicates areas where more data should possibly be collected.