Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (c...

error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. a root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. an important factor of an error occurrence is a root cause (c...

ninety percent of road traffic deaths occur in low- and middle-income countries, which claim less than half the world's registered vehicle fleet. iran and georgia have a strategic position in the region and as a bridge connect europe to asia. almost all over the world countries are planning and implementing solutions to stop tsunami of road accidents. in this paper the main challenges of r...

abstract background: many maternal deaths caused are due to preventable causes during pregnancy and childbirth. therefore, the detailed analysis of the root causes provides developing a plan and appropriate interventions to prevent these deaths occurring in the health system. this study aims to determine the causes of maternal mortality using root cause analysis (rca) method. materials and meth...

introduction: level of mothers’ literacy, pregnancy history of more than four times, residence in villages, lack of receiving intensive care during pregnancy, as well as inaccessibility to obstetric emergency services have been reported, in iran and the world, as major factors for maternal mortality. considering significance of identifying indirect causes of maternal mortalities, the present st...

errors prevention and patient safety in transfusion medicine are a serious concern. errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. to specify system vulnerabilities and illustrate the potential...

From May 2 to May 7, 2010, the Dagstuhl Seminar 10181 Program Development for Extreme-Scale Computing was held in Schloss Dagstuhl Leibniz Center for Informatics. During the seminar, several participants presented their current research, and ongoing work and open problems were discussed. Abstracts of the presentations given during the seminar as well as abstracts of seminar results and ideas ar...

M unoz, Lowry, and Smith (2012) reported the use of root cause analysis (RCA) as part of a continuous quality improvement project to reduce hypoglycemic episodes in patients following gynecological surgery. Root cause analysis is an important component of quality improvement, and nurses at all levels should understand the process and the outcomes of a RCA. Root cause analysis was used originall...

Transmission and distribution pipelines have a significant role in the oil and gas industries. Pipelines are facing different threat like corrosion, improper design and incorrect operation. Gas vapor released from a pipeline (owned by NIOC) failure spread out and reached to ignition source. Due to gas outdoor spreading, “flash fire” occurred and flame return caused “vapor cloud explosion” of ga...