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