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Effective RCA can arguably be one of the most valuable tools to any organization. This is especially true for large asset intensive companies. There are many issues that arise and if there is not a plan in place to deal with these issues then the facility can become very reactive. The challenge with effective RCA, is when do we apply the resources to identify the root causes of a problem? There are simply too many issues that arise to effectively solve every one. Therefore, a more intelligent approach must be taken to select the right issues to resolve.
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Authored and Co-Authored Books:
Root Cause Analysis: Improving Performance for Bottom Line Results – 5th Edition:
This book comprehensively outlines what a holistic and effective Root Cause Analysis (RCA) system looks like. From the designing of the support infrastructure to the measuring of effectiveness on the bottom-line, this book provides the blueprint for making it happen. While traditionally RCA is viewed as a reactive tool, the authors will show how it can be applied proactively to prevent failures from occurring in the first place. RCA is a key element of any successful Reliability Engineering initiative. Such initiatives are comprised of equipment, process and human reliability foundations. Human Reliability is critical to the success of a true RCA approach.
This book explores the anatomy of a failure (undesirable outcome) as well as a potential failure (high risks). Virtually all failures are triggered by errors of omission or commission by human beings. The methodologies described in this book are applicable to any industry because the focus is on the human being’s ability to think through why things go wrong, not on the industry or the nature of the failure. This book correlates Reliability to Safety as well as Human Performance Improvement efforts. The author has provided a healthy balance between theory and practical application, wrapping up with case studies demonstrating bottom-line results.
- Outlines in detail every aspect of an effective RCA ‘system’
- Displays appreciation for the role of understanding the physics of a failure as well as the human and system’s contribution
- Demonstrates the role of RCA in a comprehensive Asset Performance
- Management (APM) system
- Explores the correlation between Reliability Engineering and Safety
- Integrates the concepts of Human Performance Improvement, Learning Teams, and Human Error Reduction approaches into RCA
Sanya Mathura – 5th Edition RCA Book Review: It was an absolute pleasure to read “Root Cause Analysis; Improving Performance for Bottom Line Results”, Fifth Edition by Mark Latino, Bob Latino & Kenneth Latino. My brain was taken on a journey about the foundations of reliability, its implementation (at a time when it was an unheard of experience) and a greater appreciation of Root Cause Analysis. It was quite an experience!
The Latinos provide an almost forensic examination of the term Root Cause Analysis, its origins the various methods (inclusive of 5 Why, Fish Bone and Logic Tree). The pros and cons of each of the methods are discussed in great detail and allows the reader to become fully aware of each of the tools and the most appropriate instances in which they can be used.
[Read the full review here]
Managing Director & Senior Consultant at Strategic Reliability Solutions Ltd
Chapter 1. Introduction to the PROACT Root Cause Analysis (RCA) Work Process
Chapter 2. Introduction to Root Cause Analysis
Chapter 3. Creating the Environment to Succeed
Chapter 4. Failure Classification
Chapter 5. Preserving Event Data
Chapter 6. Ordering the Analysis Team
Chapter 7. Analyzing the Data
Chapter 8. Communicating Recommendations & Findings
Chapter 9. Tracking for Bottom-Line Results
Chapter 10. Proactive Human Error Reduction Techniques (HERT)
Chapter 11. The Role of RCA in Reliability and Safety
Chapter 12. RCA Investigation Management System
Chapter 13. Root Cause Analysis Case Histories
Authored By: Robert J. Latino, CEO. Reliability Center, Mark Latino, President Reliability Center, and Kenneth C. Latino, APM Product Manager, GE Digital
- Catalog no. K393125
- July 2019, 336 pp.
- ISBN: 978-1-1383-3245-4
Root Cause Analysis: Improving Performance for Bottom Line Results – 4th Edition.
Now in its fourth edition, “Root Cause Analysis: Improving Performance for bottom-Line Results” continues to explore why things don’t work out as planned and how to make sure they do. While past editions have focused on Failure Modes and Effects Analysis and Opportunity Analysis, this new edition emphasizes evidence collection and strategy and the contribution of human performance and human factors to poor decision making and understanding the human element. New topics covered include PROACTOnDemand, the advantages of SaaS, RCA templates, as well as various case studies illustrating RCA.
Robert J. Latino, Kenneth C. Latino, and Mark A. Latino 4th Edition, 2011, c. 280 pp., ISBN: 9781439850923, Taylor & Francis. Boca Raton.
Patient Safety: The PROACT Root Cause Analysis Approach.
This book addresses the proactive methodologies and organizational paradigms that must change in order to support and sustain such activities in the interest of patient safety. Written by reliability expert Robert J. Latino, this book provides a perspective on patient care from outside the health industry and culture. It teaches a proven approach that measures its effectiveness based on patient safety results, rather than compliance, and demonstrates the Return-On-Investment for using RCA to reduce and/or eliminate undesirable outcomes. Addressing the contribution of human error to physical consequences, it explores ways to identify conditions which are more prone to result in human error. It also uses FMEA to proactively identify unacceptable risks, and then uses the concepts of RCA to prevent risks from materializing.
Robert J. Latino 2008, c. 272 pp., ISBN 9781420087277, Taylor and Francis. Boca Raton.
Error Reduction in Healthcare: A Systems Approach to Improving Patient Safety.
Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur. With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors. This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.
Contributing Author: Robert J. Latino 2nd Edition, 2011 [Apr], c. 284, ISBN: 1-55648-271-X, AHA Press.
The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations.
Written for virtually every professional and leader in the health care field, as well as students who are preparing for careers in health services delivery, this book presents a framework for developing a patient safety program, shows how best to examine events that do occur, and reveals how to ensure that appropriate corrective and preventative actions are reviewed for effectiveness.
The book covers a comprehensive selection of topics including:
- The link between patient safety and legal and regulatory compliance
- The role of accreditation and standard-setting organizations in patient safety
- Failure modes and effect analysis
- Voluntary and regulatory oversight of medical error
- Evidence-based outcomes and standards of care
Contributing Author: Robert J. Latino 2005, c. 350 pp. ISBN 0-7879-6510-3, Jossey-Bass