The Latino brothers have been trail blazers in Root Cause Analysis for as long as I have known them. They have been particularly visionary in pioneering the inclusion of Human Factors into this field, via the PROACT methodology, over the past decade and a half. As always, their vision has been right on target!
Root Cause Analysis Books
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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.
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
Our Book Reviews
®Daryl Mather, Owner and Principal Consultant, Reliability Success Pty Ltd
As assets become more sophisticated, and we become more reliant on machinery, human error (and the reasons for it) are a far greater part of the reliability picture. This book will provide even greater support to companies that want to get the most out of their physical assets, and the PROACT methodology will continue to deliver unique value as they continue to evolve the method.
®Tim Stovall, CMRP, Reliability Leader, NOVA Chemicals, Inc.
"Having been involved since 1988 in the use of RCI®s root cause methodology, I know it provides repeatable success regardless of the magnitude of failure or type of industry. I can solidly contribute $10 million in savings from using the process. The knowledge in this book will stop the cycle of repeated failures.
®Alan Laundry, Tech. Services Manager, Westcoast Energy, Inc., Ft. St. John, BC.
® a technique that allowed us to fix a chronic processing problem that plagued one of our gas plants for more than ten years. If not for this technique, we would still be ®fire fighting® this problem today.
®Doug Plucknette - Eastman Kodak
Very complete course on how to perform RCA from start to finish. Real life examples of problems are excellent in making connections.
®Thomas Bublitz - Herman Miller, Inc.
... an excellent thought process stimulator. The ideas generated are excellent and much good variety of industries represented, lots of interaction and information exchanged.
®Doug Walwyn, Maintenance & Reliability Engineer, General Mills, Inc.
® am finally convinced that this is the tool of choice (when compared to RCM)
® Krishna B. Misra, in International Journal of Performability Engineering, April 2008, Vol. 4, No. 2
The reviewer would like to recommend this book to all reliability and maintenance engineers for a serious look at the material presented in the book and to reliability schools for graduating engineering students. It is a good book that explains the root cause analysis approach to engineering systems.