• Journal of Applied Reliability
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• v.16 no.1
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• pp.71-77
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• 2016

Purpose: Root cause analysis (RCA) refers to any systematic process that identifies the causes that contribute to a focus event. The immediate cause of a focus event is often a symptom of underlying causes and may not truly identify the root causes that should be identified and addressed. Currently many RCA tools are available. Different investigators use different RCA tools on different issues. No standardized or commonly agreed way to analyse root causes exists. The purpose of this study is to propose the methodology of RCA process commonly useable for various issues. Methods: The methodology of RCA process is produced based on the hybrid RCA tools. The effectiveness assessment matrix of actions through the root cause candidates is presented. Results: No single RCA technique proposed has so far covered all necessary aspects. A hybrid approach which combines the best features of various techniques is proposed. The effectiveness assessment matrix helps us to identify the root cause to correct or eliminate system vulnerabilities effectively. Conclusion: This hybrid approach and effectiveness assessment matrix can provide guidance of RCA process across many industries and situations.

• Quality Improvement in Health Care
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• v.23 no.1
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• pp.25-38
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• 2017

Root cause analysis (RCA) is systematic process for identifying contributing factors and root causes. It detects system-level vulnerabilities and prevents them from occurring in the future. In many countries, RCA guidelines have been developed and used for these purposes, and various practical tools are suggested according to stages of RCA implementation. In Korea, adverse events occur in 7.2-8.3 percent of inpatients according to studies conducted in hospitals. However, frontline staffs are suffering from lack of knowledge about RCA implementation. This study introduces RCA guidelines that may be used in hospitals to improve the quality of medical care and patient safety.

• Quality Improvement in Health Care
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• v.23 no.1
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• pp.11-23
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• 2017

Root Cause Analysis (RCA) has been widely used as a structured approach to investigate patient safety incidents. RCA helps identify what, how, and why something happened, therefore preventing recurrence of incidents. Since many quality tools can be used during RCA, various formats of RCA exist. If RCAs are performed incorrectly or incompletely, they are likely to produce unusable results. To address this issue, RCA software has been developed. The use of RCA software in investigating patient safety incidents may offer several advantages, such as potential reduction in learning time, shortening of the analytic process, facilitation of collection, analysis, and presentation of data and production of meaningful RCA reports. We introduced six healthcare RCA software and compared characteristics. Results from this study will enable the RCA team to choose proper RCA software.

• Quality Improvement in Health Care
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• v.24 no.1
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• pp.9-22
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• 2018

Purpose: The purpose of this study is to develop the Korean root cause analysis (RCA) software that can be used to systematically investigate underlying causes for preventing or reducing recurrence of patient safety incidents. Methods: We reviewed the existing guidelines and literatures on the RCA in order to figure out the RCA process. Also we examined the existing RCA softwares for investigating patient safety incidents to design the contents and interface of the RCA software. Based on the results of reviewing literatures and softwares, we developed a draft version of the Korean RCA software that can be easily used in Korean hospital settings by RCA teams. Results: The Korean RCA software consisted of several modules, which are modules for identifying patient safety incidents, organizing RCA team, collecting and analysing data, determining contributory factors and root causes, developing the action plans, and guiding evaluation. Conclusion: The Korean RCA software included optimized RCA process and structured logic for cause analysis. Thus even beginners in RCA are expected to easily use this software for investigating patient safety incidents. As software has been developed with the public financial support, it will be distributed free of charge. We hope that it will contribute to facilitating patient safety improvement activities in Korea.

• Journal of the Korean Society of Safety
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• v.36 no.5
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• pp.43-51
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• 2021

Incident investigation is one of the most important processes among various other safety management methods to prevent industrial accidents. Finding the root causes of accidents, eliminating hazards, and improving safety are the most important purposes of investigating accidents. During the investigation process, root cause analysis (RCA) techniques are used to effectively identify RCA. Over the past few decades, over 30 RCA methods have been developed. These techniques are being widely used in some industries, such as the nuclear and aircraft industries; however, most of the RCA techniques require professional knowledge and special training, making it difficult for safety managers in their respective fields to understand and apply them. Therefore, managers of general industrial sites are rarely present at the scene of actual accident investigations, and they cannot contribute much to the purpose and effectiveness of these investigations. In this study, to address these issues, we developed an RCA technique to facilitate root cause investigation of accidents in real-world industrial sites. To develop new techniques, Systematic Cause Analysis Technique (SCAT), one of the RCA techniques, was used to investigate incidents in the enterprise over three years. We also utilized feature analysis and other papers from existing RCA techniques. To verify its effectiveness, the technique proposed was also applied to the accident case. The technique developed can easily identify and analyze the root cause of an accident and help industrial managers. It can also identify the root cause category where accidents are concentrated and use this data to establish guidelines for preventing future accidents and, thus, focus on prioritizing improvement initiatives.

• Journal of the Korean Institute of Gas
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• v.18 no.4
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• pp.86-94
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• 2014

To develop a Root Cause Analysis Map which determines the cause of the accident in chemical laboratory, The Root Cause Analysis(RCA) Map for the laboratory areas was sketched from Phase 1 of the accident element to Phase 3 of the accident element, based on the RCA Map which is applied in the petrochemical industry. On the basis of laboratory RCA Map which was classified by using such method. The root causes of the 211 accident cases in laboratories were classified from Phase 4 to Phase 5 by the Cause Factor Charting technique and The cause of the accident data were inputted to EXCEL program. After that, The causes of the accident data were sorted and classified by type and each step. So 'Approximate Primary RCA Map Draft' was written. In addition, it was reaffirmed whether the root causes of 211 accidents of laboratory were appropriate to 'Primary RCA Map Draft'. By complementing the cause which was expected to cause future accidents, the RCA Map for chemical laboratories was developed. Based on 'RCA Map' proposed in this study, the causes of accidents were analysed management systems 35%, monitoring 12.2%, Human Factor Eng. 15.1% and education training 12.1% by the size of the frequency from Phase 1 to Phase 5.

• Journal of Digital Convergence
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• v.12 no.8
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• pp.77-84
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• 2014

TRIZ was developed and refined in the Soviet Union between 1946 and 1985 by Genrich Altshuller. Its primary application has been for solving inventive problems in the areas of engineering. But, recently the elements of TRIZ began to be applied non-technical areas by Darrell Mann. TRIZ theroy was brought into South Korea in 1995 and it is used by the LG, SAMSUNG, POSCO. TRIZ is simply not the tool for technical problem solving, covering many areas of comprehensive approach is being recognized. TRIZ is a methodology for defining problem, finding root cause through RCA(Root cause analysis), defining technical contradiction and physical contradiction. TRIZ overcomes contradiction and purses problem solving method through innovation. TRIZ is a problem solving method in this study using the principles of non-technical fields applied to the improvement of the logistics area study. The method to overcome contradiction is 40 principles. It is possible to generate idea by using 40 principles. This study was applied to logistics field of non-technical area by using TRIZ principle.

• Korean Journal of Hazardous Materials
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• v.6 no.2
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• pp.47-54
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• 2018

Mixed acid is very reactive and highly corrosive. it has been causing many accidents in a electronic industry, a steel industry, and a chemical industry. Therefore, it is required that the high safety level for the acid storage facilities. In this study, we investigated the accident causes for resent leak accidents with Root Cause Analysis (RCA). The root causes analysed by RCA were categorized as nine divisions by the their characteristics. Furthermore, each nine divisions causes was applied to the PDCA model which are using at OHSAS 18001. It is suggested that the nine division with the root causes can be the essential items for the development of the safety management manual. It is helpful to the safety improvement of the acid storage facility.

• The Korean Journal of Health Service Management
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• v.13 no.3
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• pp.13-26
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• 2019

Objectives: To investigate whether medical institutions can prevent accidents by analyzing the root cause of a medical accident and identifying the tendencies. Methods: A total of 345 medical cases were used for the RCA(Root Cause Analysis). The root causes were classified using the SHELL model. The suitability of the model was confirmed by SPSS's MDPREF and Euclidean distance. An SPSS20.0 hierarchical regression analysis was used as an influencing factor on the degree of injury resulting from medical accidents. Results: The SHELL model was suitable for classification. The rates of accident causes were LS49%, L34%, LL10.2%, LE3.7%, LH2.3%. The order in which the degree of a patient's injury was affected were: Risk Threshold (${\beta}=.180$), Time (${\beta}=.175$), Surgical stage (${\beta}=-.166$), Do not use procedure (${\beta}=.147$). Conclusions: Health care institutions should remove priorities through system improvement and training. For patients' safety, the five factors of the SHELL model should be managed in harmony.

• Safety and Health at Work
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• v.12 no.4
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• pp.496-504
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• 2021

Background: With the increasing demand for industrial robots and the "noncontact" trend, it is an appropriate point in time to examine whether risk assessments conducted for robot operations are performed effectively to identify and eliminate the risks of injury or harm to operators. This study discusses why robot accidents resulting in harm to operators occur repetitively despite implementing control measures and proposes corrective actions for risk assessments. Methods: This study collected 369 operator-injured robot accidents in Korea over the last decade and reconstructed them into the mechanism of injury, work being undertaken, and bodily location of the injury. Then, through the techniques of Systematic Cause Analysis Technique (SCAT) and Root Cause Analysis (RCA), this study analyzed the root and direct causes of robot accidents that had occurred. Causes identified included physical hazards and complex combinations of hazards, such as psychological, organizational, and systematic errors. The requirements of risk assessments regarding robot operations were examined, and three case studies of robot-involved tasks were investigated. The three assessments presented were: camera module processing, electrical discharge machining, and a panel-flipping robot installation. Results: After conducting RCA and comparing the three assessments, it was found that two-thirds of injury-occurring from robot accidents, causative factors included psychological and personal traits of robot operators. However, there were no evaluations of the identifications of personal aspects in the three assessment cases. Conclusion: Therefore, it was concluded that personal factors of operators, which had been overlooked in risk assessments so far, need to be included in future risk assessments on robot operations.