Do you have any experience using the Root Cause Analysis (RCA) methodology to identify the actual causes of a problem?

For this discussion, we are going to attack Medical Device User Errors.

Our reference is an article titled “Six Things We Can Do About ” by Conrad Stolze. This article is more than a couple of years old, but I promise the BMET/User struggle is still alive and well across the medical world.

Safely using any medical device requires balancing many factors from equipment to the user. Of course, the equipment can fail to operate correctly and on rare occasions, this is the case. However, it is more common for the user to incorrectly operate and configure the equipment causing unexpected operation or harm to a patient. (Stolze, 2007)

Link: (Links to an external site.)

After reading the article, post your thoughts covering one or some of the following areas. 

  • Do you have any experience using the (RCA) methodology to identify the actual causes of a problem?
  • Compare and contrast 2 pieces of equipment (any type); one that is a ‘Good’ example of a simple user interface and one that is ‘Bad’, aka overly complicated.
  • If you were called to a medical ward to perform an Incident Investigation, what are some questions you might ask the user(s)?


Stolze, C. (2007, Jan 31). Six Things We Can Do About User Errors. Retrieved from 24×7 Magazine:

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