{"id":29701,"date":"2023-09-29T09:11:20","date_gmt":"2023-09-29T12:11:20","guid":{"rendered":"https:\/\/mindthegraph.com\/blog\/what-is-a-doi-copy\/"},"modified":"2023-09-27T09:22:23","modified_gmt":"2023-09-27T12:22:23","slug":"root-cause-analysis","status":"publish","type":"post","link":"https:\/\/mindthegraph.com\/blog\/zh\/%e6%a0%b9%e6%ba%90%e5%88%86%e6%9e%90\/","title":{"rendered":"\u4ece\u75c7\u72b6\u5230\u89e3\u51b3\u65b9\u6848\uff1a\u6839\u6e90\u5206\u6790\u7684\u827a\u672f"},"content":{"rendered":"<p>\u60a8\u662f\u5426\u538c\u5026\u4e86\u91cd\u590d\u5904\u7406\u540c\u6837\u7684\u95ee\u9898\uff1f\u5373\u4f7f\u4f60\u8ba4\u4e3a\u81ea\u5df1\u5df2\u7ecf\u627e\u5230\u4e86\u89e3\u51b3\u65b9\u6848\uff0c\u4f60\u53ef\u80fd\u4ecd\u7136\u4f1a\u88ab\u8fd9\u4e2a\u95ee\u9898\u6240\u56f0\u6270\u3002\u51fa\u73b0\u8fd9\u79cd\u60c5\u51b5\u7684\u539f\u56e0\u662f\uff0c\u4f60\u76f4\u63a5\u8df3\u5165\u4e86\u5bfb\u627e\u7b54\u6848\u7684\u9636\u6bb5\uff0c\u800c\u4e0d\u662f\u53bb\u4e86\u89e3\u95ee\u9898\u7684\u539f\u56e0\u3002\u5982\u679c\u4f60\u82b1\u65f6\u95f4\u5206\u6790\u95ee\u9898\u80cc\u540e\u7684\u771f\u6b63\u539f\u56e0\uff0c\u5c31\u4f1a\u5f88\u5bb9\u6613\u51fb\u5012\u4f60\u7684\u95ee\u9898\uff0c\u9632\u6b62\u5b83\u53cd\u590d\u51fa\u73b0\u3002\u8fd9\u6837\u7684\u8fc7\u7a0b\u88ab\u79f0\u4e3a <strong>\u6839\u672c\u539f\u56e0\u5206\u6790<\/strong>.&nbsp;<\/p>\n\n\n\n<p>\u6839\u672c\u539f\u56e0\u5206\u6790\u662f\u516c\u53f8\u5728\u51fa\u73b0\u95ee\u9898\u65f6\u91c7\u7528\u7684\u4e00\u79cd\u6280\u672f\u3002\u5728\u672c\u6587\u4e2d\uff0c\u6211\u4eec\u5c06\u901a\u8fc7\u5b9e\u4f8b\u6df1\u5165\u4e86\u89e3\u8fd9\u4e00\u6982\u5ff5\u3001\u7c7b\u578b\u548c\u6280\u5de7\u3002<\/p>\n\n\n\n<h2 id=\"h-root-cause-analysis-steps-tools-and-examples\">\u6839\u672c\u539f\u56e0\u5206\u6790\uff1a\u6b65\u9aa4\u3001\u5de5\u5177\u548c\u793a\u4f8b<\/h2>\n\n\n\n<p>\u6839\u672c\u539f\u56e0\u5206\u6790 (RCA) \u662f\u4e00\u79cd\u89e3\u51b3\u95ee\u9898\u7684\u6280\u672f\uff0c\u7528\u4e8e\u627e\u51fa\u95ee\u9898\u6216\u4e8b\u4ef6\u7684\u6839\u672c\u539f\u56e0\u3002\u5176\u76ee\u7684\u662f\u627e\u51fa\u95ee\u9898\u53d1\u751f\u7684\u6839\u672c\u539f\u56e0\uff0c\u800c\u4e0d\u4ec5\u4ec5\u662f\u5bf9\u75c7\u4e0b\u836f\u3002RCA \u53ef\u5e2e\u52a9\u7ec4\u7ec7\u6216\u4e2a\u4eba\u66f4\u6df1\u5165\u5730\u4e86\u89e3\u95ee\u9898\uff0c\u9632\u6b62\u95ee\u9898\u518d\u6b21\u53d1\u751f\uff0c\u5e76\u5b9e\u65bd\u6709\u6548\u7684\u7ea0\u6b63\u63aa\u65bd\u3002&nbsp;<\/p>\n\n\n\n<p>\u4ee5\u4e0b\u662f RCA \u7684\u4e00\u822c\u6b65\u9aa4\u3001\u5e38\u7528\u5de5\u5177\u548c\u793a\u4f8b\uff1a<\/p>\n\n\n\n<h2 id=\"h-steps-of-root-cause-analysis\">\u6839\u672c\u539f\u56e0\u5206\u6790\u7684\u6b65\u9aa4<\/h2>\n\n\n\n<ol>\n<li><strong>\u786e\u5b9a\u95ee\u9898\uff1a <\/strong>\u660e\u786e\u754c\u5b9a\u9700\u8981\u8fdb\u884c RCA \u5206\u6790\u7684\u95ee\u9898\u6216\u4e8b\u4ef6\u3002\u786e\u5b9a\u5206\u6790\u7684\u8303\u56f4\u548c\u754c\u9650\u3002<\/li>\n\n\n\n<li><strong>\u6536\u96c6\u6570\u636e\uff1a <\/strong>\u6536\u96c6\u4e0e\u95ee\u9898\u76f8\u5173\u7684\u6570\u636e\u3002\u8fd9\u53ef\u4ee5\u5305\u62ec\u4e8b\u6545\u62a5\u544a\u3001\u6d41\u7a0b\u6587\u6863\u3001\u5ba2\u6237\u53cd\u9988\u4ee5\u53ca\u4efb\u4f55\u5176\u4ed6\u53ef\u7528\u4fe1\u606f\u3002<\/li>\n\n\n\n<li><strong>\u627e\u51fa\u76f4\u63a5\u539f\u56e0\uff1a<\/strong> \u786e\u5b9a\u76f4\u63a5\u5bfc\u81f4\u95ee\u9898\u7684\u539f\u56e0\u6216\u4e8b\u4ef6\u3002\u8fd9\u4e9b\u901a\u5e38\u662f\u95ee\u9898\u6700\u660e\u663e\u7684\u75c7\u72b6\u3002<\/li>\n\n\n\n<li><strong>\u95ee \"\u4e3a\u4ec0\u4e48\uff1f\"\u5e76\u627e\u51fa\u4fc3\u6210\u56e0\u7d20\uff1a<\/strong> \u4ece\u4e0a\u4e00\u6b65\u786e\u5b9a\u7684\u76f4\u63a5\u539f\u56e0\u5f00\u59cb\uff0c\u8be2\u95ee <strong>\"\u4e3a\u4ec0\u4e48\u4f1a\u53d1\u751f\u8fd9\u79cd\u4e8b\uff1f\"<\/strong> \u5e76\u6df1\u5165\u6316\u6398\uff0c\u627e\u51fa\u9020\u6210\u6bcf\u4e2a\u76f4\u63a5\u539f\u56e0\u7684\u6f5c\u5728\u56e0\u7d20\u3002\u5bf9\u6bcf\u4e2a\u7b54\u6848\u7ee7\u7eed\u8ffd\u95ee \"\u4e3a\u4ec0\u4e48\uff1f\"\uff0c\u76f4\u5230\u627e\u5230\u6839\u672c\u539f\u56e0\u3002<\/li>\n\n\n\n<li><strong>\u786e\u5b9a\u6839\u672c\u539f\u56e0\uff1a<\/strong> \u5206\u6790\u8bf1\u56e0\uff0c\u627e\u51fa\u6839\u672c\u539f\u56e0\uff0c\u5982\u679c\u89e3\u51b3\u4e86\u8fd9\u4e9b\u6839\u672c\u539f\u56e0\uff0c\u5c31\u80fd\u9632\u6b62\u95ee\u9898\u518d\u6b21\u53d1\u751f\u3002\u6839\u672c\u539f\u56e0\u901a\u5e38\u662f\u6700\u6df1\u5c42\u6b21\u7684\u6f5c\u5728\u95ee\u9898\uff0c\u5982\u679c\u5f97\u5230\u89e3\u51b3\uff0c\u5c31\u80fd\u6d88\u9664\u6216\u5927\u5927\u7f13\u89e3\u95ee\u9898\u3002<\/li>\n\n\n\n<li><strong>\u9a8c\u8bc1\u6839\u672c\u539f\u56e0\uff1a<\/strong> \u901a\u8fc7\u68c0\u67e5\u652f\u6301\u8bc1\u636e\u5e76\u786e\u4fdd\u5176\u4e0e\u53ef\u7528\u6570\u636e\u4e00\u81f4\uff0c\u9a8c\u8bc1\u5df2\u786e\u5b9a\u7684\u6839\u672c\u539f\u56e0\u3002\u8fd9\u4e00\u6b65\u9aa4\u6709\u52a9\u4e8e\u63d0\u9ad8\u5206\u6790\u7684\u51c6\u786e\u6027\u548c\u53ef\u9760\u6027\u3002<\/li>\n\n\n\n<li><strong>\u5b9e\u65bd\u7ea0\u6b63\u63aa\u65bd\uff1a <\/strong>\u5c06\u7ea0\u6b63\u63aa\u65bd\u4ed8\u8bf8\u5b9e\u8df5\u3002\u5206\u914d\u8d23\u4efb\u3001\u8bbe\u5b9a\u65f6\u95f4\u8868\uff0c\u5e76\u5c06\u8ba1\u5212\u4f20\u8fbe\u7ed9\u76f8\u5173\u5229\u76ca\u6538\u5173\u65b9\u3002<\/li>\n\n\n\n<li><strong>\u76d1\u6d4b\u548c\u8bc4\u4f30\uff1a <\/strong>\u6301\u7eed\u76d1\u63a7\u5df2\u5b9e\u65bd\u7684\u7ea0\u6b63\u63aa\u65bd\u5e76\u8bc4\u4f30\u5176\u6709\u6548\u6027\u3002\u786e\u4fdd\u95ee\u9898\u4e0d\u518d\u53d1\u751f\uff0c\u5e76\u8861\u91cf\u5df2\u5b9e\u65bd\u884c\u52a8\u7684\u5f71\u54cd\u3002<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-tools-for-root-cause-analysis\">\u6839\u672c\u539f\u56e0\u5206\u6790\u5de5\u5177<\/h2>\n\n\n\n<ol>\n<li><strong>5 \u4e3a\u4ec0\u4e48\uff1f<\/strong> 5 \u4e2a\u4e3a\u4ec0\u4e48 \"\u6280\u5de7\u662f\u6307\u53cd\u590d\u95ee \"\u4e3a\u4ec0\u4e48\uff1f\"\u4ee5\u627e\u5230\u95ee\u9898\u7684\u6839\u672c\u539f\u56e0\u3002\u81f3\u5c11\u95ee 5 \u6b21 \"\u4e3a\u4ec0\u4e48\"\uff0c\u5c31\u80fd\u53d1\u73b0\u66f4\u6df1\u5c42\u6b21\u7684\u539f\u56e0\u3002<\/li>\n\n\n\n<li><strong>\u9c7c\u9aa8\u56fe (<\/strong><a href=\"https:\/\/en.wikipedia.org\/wiki\/Ishikawa_diagram\"><strong>\u77f3\u5ddd\u56fe<\/strong><\/a><strong>):<\/strong> \u9c7c\u9aa8\u56fe\u5c06\u95ee\u9898\u7684\u6f5c\u5728\u539f\u56e0\u5206\u4e3a\u4eba\u5458\u3001\u6d41\u7a0b\u3001\u8bbe\u5907\u3001\u6750\u6599\u548c\u73af\u5883\u7b49\u5177\u4f53\u7c7b\u522b\uff0c\u6709\u52a9\u4e8e\u76f4\u89c2\u5730\u4e86\u89e3\u95ee\u9898\u7684\u6f5c\u5728\u539f\u56e0\u3002<\/li>\n\n\n\n<li><a href=\"https:\/\/en.wikipedia.org\/wiki\/Fault_tree_analysis\"><strong>\u6545\u969c\u6811\u5206\u6790<\/strong><\/a><strong> (FTA\uff09\uff1a<\/strong> FTA \u662f\u4e00\u79cd\u56fe\u5f62\u5de5\u5177\uff0c\u7528\u4e8e\u8bc6\u522b\u548c\u5206\u6790\u53ef\u80fd\u5bfc\u81f4\u7279\u5b9a\u610f\u5916\u7ed3\u679c\u7684\u4e8b\u4ef6\u7ec4\u5408\u3002\u5b83\u6709\u52a9\u4e8e\u786e\u5b9a\u95ee\u9898\u53d1\u751f\u65f6\u5fc5\u987b\u53d1\u751f\u7684\u6700\u5c0f\u4e8b\u4ef6\u96c6\u3002<\/li>\n\n\n\n<li><a href=\"https:\/\/en.wikipedia.org\/wiki\/Pareto_analysis\"><strong>\u5e15\u7d2f\u6258\u5206\u6790<\/strong><\/a><strong>: <\/strong>\u5e15\u7d2f\u6258\u5206\u6790\u6cd5\u662f\u6839\u636e\u6f5c\u5728\u539f\u56e0\u7684\u53d1\u751f\u9891\u7387\u6216\u5f71\u54cd\u7a0b\u5ea6\u786e\u5b9a\u5176\u4f18\u5148\u6b21\u5e8f\u3002\u5b83\u6709\u52a9\u4e8e\u627e\u51fa\u5bf9\u95ee\u9898\u5f71\u54cd\u6700\u5927\u7684\u51e0\u4e2a\u91cd\u8981\u539f\u56e0\u3002<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-example-of-root-cause-analysis\">\u6839\u672c\u539f\u56e0\u5206\u6790\u793a\u4f8b<\/h2>\n\n\n\n<p>\u8ba9\u6211\u4eec\u4ee5\u4ea7\u54c1\u5236\u9020\u7f3a\u9677\u4e3a\u4f8b<\/p>\n\n\n\n<ol>\n<li><strong>\u76f4\u63a5\u539f\u56e0 <\/strong>\u4ea7\u54c1\u5728\u73b0\u573a\u51fa\u73b0\u6545\u969c\u3002<\/li>\n\n\n\n<li><strong>\u4e3a\u4ec0\u4e48\uff1f<\/strong> \u751f\u4ea7\u8fc7\u7a0b\u4e2d\u8d28\u91cf\u63a7\u5236\u4e0d\u4e25\u3002<\/li>\n\n\n\n<li><strong>\u4fc3\u6210\u56e0\u7d20<\/strong> \u751f\u4ea7\u4eba\u5458\u57f9\u8bad\u4e0d\u8db3\uff0c\u8bbe\u5907\u9648\u65e7\u3002<\/li>\n\n\n\n<li><strong>\u6839\u672c\u539f\u56e0\uff1a<\/strong> \u5bf9\u5458\u5de5\u57f9\u8bad\u548c\u8bbe\u5907\u5347\u7ea7\u7684\u6295\u8d44\u4e0d\u8db3\u3002<\/li>\n\n\n\n<li><strong>\u7ea0\u6b63\u884c\u52a8\uff1a<\/strong> \u5b9e\u65bd\u5168\u9762\u7684\u5458\u5de5\u57f9\u8bad\u8ba1\u5212\uff0c\u5e76\u4e3a\u8bbe\u5907\u5347\u7ea7\u5212\u62e8\u8d44\u91d1\u3002<\/li>\n<\/ol>\n\n\n\n<h3 id=\"h-how-does-the-project-manager-help-with-analysis\">\u9879\u76ee\u7ecf\u7406\u5982\u4f55\u5e2e\u52a9\u5206\u6790\uff1f<\/h3>\n\n\n\n<p>\u9879\u76ee\u7ecf\u7406\u5728\u4fc3\u8fdb\u6839\u672c\u539f\u56e0\u5206\u6790\u8fc7\u7a0b\u548c\u786e\u4fdd\u5176\u6709\u6548\u6027\u65b9\u9762\u53d1\u6325\u7740\u81f3\u5173\u91cd\u8981\u7684\u4f5c\u7528\u3002\u4ee5\u4e0b\u662f\u9879\u76ee\u7ecf\u7406\u53ef\u4ee5\u5e2e\u52a9\u8fdb\u884c\u5206\u6790\u7684\u65b9\u6cd5\uff1a<\/p>\n\n\n\n<ol>\n<li><strong>\u4fc3\u8fdb RCA \u6d41\u7a0b\uff1a<\/strong> \u9879\u76ee\u7ecf\u7406\u53ef\u4ee5\u901a\u8fc7\u7ec4\u7ec7\u4f1a\u8bae\u3001\u8bbe\u7f6e\u5fc5\u8981\u7684\u5de5\u5177\u548c\u6307\u5bfc\u56e2\u961f\u5b8c\u6210\u5206\u6790\u6b65\u9aa4\u6765\u9886\u5bfc\u548c\u4fc3\u8fdb RCA \u6d41\u7a0b\u3002\u4ed6\u4eec\u53ef\u786e\u4fdd\u5206\u6790\u5de5\u4f5c\u91cd\u70b9\u7a81\u51fa\u3001\u5bcc\u6709\u6210\u6548\u5e76\u6b65\u5165\u6b63\u8f68\u3002<\/li>\n\n\n\n<li><strong>\u63d0\u4f9b\u9879\u76ee\u80cc\u666f\uff1a <\/strong>\u9879\u76ee\u7ecf\u7406\u5168\u9762\u4e86\u89e3\u9879\u76ee\u7684\u76ee\u6807\u3001\u76ee\u7684\u548c\u9650\u5236\u56e0\u7d20\u3002\u4ed6\u4eec\u53ef\u4ee5\u4e3a RCA \u56e2\u961f\u63d0\u4f9b\u5b9d\u8d35\u7684\u80cc\u666f\u4fe1\u606f\uff0c\u5e2e\u52a9\u4ed6\u4eec\u4e86\u89e3\u95ee\u9898\u6216\u4e8b\u4ef6\u5982\u4f55\u878d\u5165\u66f4\u5927\u7684\u9879\u76ee\u6846\u67b6\u3002\u8fd9\u4e9b\u80cc\u666f\u4fe1\u606f\u6709\u52a9\u4e8e\u786e\u5b9a\u76f8\u5173\u7684\u4fc3\u6210\u56e0\u7d20\u548c\u6839\u672c\u539f\u56e0\u3002<\/li>\n\n\n\n<li><strong>\u6536\u96c6\u76f8\u5173\u6570\u636e\uff1a <\/strong>\u9879\u76ee\u7ecf\u7406\u53ef\u4ee5\u534f\u52a9\u6536\u96c6\u548c\u6574\u7406 RCA \u7684\u76f8\u5173\u6570\u636e\u3002\u4ed6\u4eec\u53ef\u4ee5\u83b7\u5f97\u9879\u76ee\u6587\u6863\u3001\u7ee9\u6548\u6307\u6807\u3001\u5229\u76ca\u76f8\u5173\u8005\u53cd\u9988\u4ee5\u53ca\u5176\u4ed6\u4fe1\u606f\u6765\u6e90\u3002\u901a\u8fc7\u6574\u7406\u8fd9\u4e9b\u6570\u636e\u5e76\u5c06\u5176\u63d0\u4ea4\u7ed9 RCA \u56e2\u961f\uff0c\u9879\u76ee\u7ecf\u7406\u53ef\u786e\u4fdd\u5206\u6790\u4fe1\u606f\u5145\u5206\u4e14\u57fa\u4e8e\u51c6\u786e\u7684\u4fe1\u606f\u3002<\/li>\n\n\n\n<li><strong>\u8ba9\u5229\u76ca\u6538\u5173\u65b9\u53c2\u4e0e\u8fdb\u6765\uff1a<\/strong> \u5229\u76ca\u76f8\u5173\u8005\u901a\u5e38\u5bf9\u5f53\u524d\u7684\u95ee\u9898\u6709\u5b9d\u8d35\u7684\u89c1\u89e3\u548c\u89c2\u70b9\u3002\u9879\u76ee\u7ecf\u7406\u53ef\u8ba9\u56e2\u961f\u6210\u5458\u3001\u5ba2\u6237\u548c\u4e3b\u9898\u4e13\u5bb6\u7b49\u5229\u76ca\u76f8\u5173\u8005\u53c2\u4e0e RCA \u6d41\u7a0b\u3002\u8fd9\u79cd\u53c2\u4e0e\u53ef\u4ee5\u63d0\u4f9b\u4e0d\u540c\u7684\u89c2\u70b9\uff0c\u63d0\u9ad8\u5206\u6790\u7684\u51c6\u786e\u6027\u548c\u5b8c\u6574\u6027\u3002<\/li>\n\n\n\n<li><strong>\u652f\u6301\u51b3\u7b56\uff1a<\/strong> \u5728 RCA \u8fc7\u7a0b\u4e2d\uff0c\u56e2\u961f\u53ef\u80fd\u4f1a\u9047\u5230\u591a\u4e2a\u6f5c\u5728\u7684\u6839\u672c\u539f\u56e0\u3002\u9879\u76ee\u7ecf\u7406\u53ef\u4ee5\u6839\u636e\u8fd9\u4e9b\u539f\u56e0\u7684\u5f71\u54cd\u3001\u53ef\u884c\u6027\u4ee5\u53ca\u4e0e\u9879\u76ee\u76ee\u6807\u7684\u4e00\u81f4\u6027\uff0c\u534f\u52a9\u8bc4\u4f30\u8fd9\u4e9b\u539f\u56e0\u5e76\u786e\u5b9a\u5176\u4f18\u5148\u6b21\u5e8f\u3002\u4ed6\u4eec\u53ef\u4ee5\u5e2e\u52a9\u56e2\u961f\u5c31\u9009\u62e9\u6839\u672c\u539f\u56e0\u548c\u5236\u5b9a\u9002\u5f53\u7684\u7ea0\u6b63\u63aa\u65bd\u505a\u51fa\u660e\u667a\u7684\u51b3\u7b56\u3002<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-benefits-and-goals-of-root-cause-analysis\">\u6839\u6e90\u5206\u6790\u7684\u76ca\u5904\u548c\u76ee\u6807<\/h2>\n\n\n\n<p>\u6839\u672c\u539f\u56e0\u5206\u6790\u7684\u76ca\u5904\u548c\u76ee\u6807\u5305\u62ec<\/p>\n\n\n\n<ol>\n<li><strong>\u89e3\u51b3\u95ee\u9898\uff1a <\/strong>RCA \u65e8\u5728\u627e\u51fa\u95ee\u9898\u6216\u4e8b\u4ef6\u7684\u6839\u672c\u539f\u56e0\uff0c\u800c\u4e0d\u4ec5\u4ec5\u662f\u89e3\u51b3\u75c7\u72b6\u3002\u901a\u8fc7\u8bc6\u522b\u548c\u89e3\u51b3\u6839\u672c\u539f\u56e0\uff0cRCA \u6709\u52a9\u4e8e\u4ece\u6839\u6e90\u4e0a\u89e3\u51b3\u95ee\u9898\uff0c\u4ece\u800c\u627e\u5230\u957f\u671f\u7684\u89e3\u51b3\u65b9\u6848\u3002<\/li>\n\n\n\n<li><strong>\u9632\u6b62\u590d\u53d1\uff1a<\/strong> RCA \u7684\u91cd\u70b9\u662f\u4e86\u89e3\u95ee\u9898\u53d1\u751f\u7684\u6700\u521d\u539f\u56e0\u3002\u901a\u8fc7\u89e3\u51b3\u6839\u672c\u539f\u56e0\uff0c\u4f01\u4e1a\u53ef\u4ee5\u5b9e\u65bd\u7ea0\u6b63\u63aa\u65bd\uff0c\u9632\u6b62\u95ee\u9898\u518d\u6b21\u53d1\u751f\u3002\u8fd9\u6709\u52a9\u4e8e\u63d0\u9ad8\u6574\u4f53\u8fd0\u8425\u6548\u7387\uff0c\u964d\u4f4e\u4eca\u540e\u53d1\u751f\u7c7b\u4f3c\u95ee\u9898\u7684\u53ef\u80fd\u6027\u3002<\/li>\n\n\n\n<li><strong>\u6539\u8fdb\u6d41\u7a0b\uff1a<\/strong> RCA \u63d0\u4f9b\u4e86\u5bf9\u6d41\u7a0b\u4f4e\u6548\u3001\u74f6\u9888\u6216\u5dee\u8ddd\u7684\u6d1e\u5bdf\u529b\u3002\u901a\u8fc7\u627e\u51fa\u6839\u672c\u539f\u56e0\uff0c\u4f01\u4e1a\u53ef\u4ee5\u6709\u9488\u5bf9\u6027\u5730\u6539\u8fdb\u6d41\u7a0b\uff0c\u4ece\u800c\u63d0\u9ad8\u6548\u7387\u3001\u964d\u4f4e\u6210\u672c\u548c\u63d0\u9ad8\u8d28\u91cf\u3002<\/li>\n\n\n\n<li><strong>\u5b66\u4e60\u548c\u77e5\u8bc6\u5171\u4eab\uff1a<\/strong> RCA \u5021\u5bfc\u4ece\u9519\u8bef\u4e2d\u5b66\u4e60\u5e76\u5728\u6574\u4e2a\u7ec4\u7ec7\u5185\u5171\u4eab\u77e5\u8bc6\u7684\u6587\u5316\u3002\u5b83\u9f13\u52b1\u56e2\u961f\u5206\u6790\u548c\u8bb0\u5f55\u4ed6\u4eec\u7684\u53d1\u73b0\uff0c\u4f7f\u5176\u4ed6\u4eba\u80fd\u591f\u4ece\u8fc7\u53bb\u7684\u7ecf\u9a8c\u4e2d\u5438\u53d6\u6559\u8bad\uff0c\u9632\u6b62\u5728\u5de5\u4f5c\u4e2d\u51fa\u73b0\u7c7b\u4f3c\u95ee\u9898\u3002<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-principles-of-root-cause-analysis\">\u6839\u672c\u539f\u56e0\u5206\u6790\u7684\u539f\u5219<\/h2>\n\n\n\n<p>\u6839\u672c\u539f\u56e0\u5206\u6790\u9075\u5faa\u51e0\u9879\u5173\u952e\u539f\u5219\uff0c\u6709\u52a9\u4e8e\u786e\u4fdd\u5176\u6709\u6548\u6027\u548c\u51c6\u786e\u6027\u3002\u8fd9\u4e9b\u539f\u5219\u5305\u62ec<\/p>\n\n\n\n<h3 id=\"h-systemic-approach\">\u7cfb\u7edf\u65b9\u6cd5<\/h3>\n\n\n\n<p>RCA \u5c06\u95ee\u9898\u7f6e\u4e8e\u53d1\u751f\u95ee\u9898\u7684\u7cfb\u7edf\u6216\u6d41\u7a0b\u7684\u5927\u80cc\u666f\u4e0b\u8fdb\u884c\u8003\u8651\u3002\u5b83\u8ba4\u8bc6\u5230\u95ee\u9898\u5f80\u5f80\u662f\u7531\u76f8\u4e92\u5173\u8054\u7684\u56e0\u7d20\u548c\u5404\u7ec4\u6210\u90e8\u5206\u4e4b\u95f4\u7684\u76f8\u4e92\u4f5c\u7528\u9020\u6210\u7684\u3002\u901a\u8fc7\u91c7\u7528\u7cfb\u7edf\u65b9\u6cd5\uff0cRCA \u8bd5\u56fe\u4e86\u89e3\u6574\u4e2a\u7cfb\u7edf\u7684\u52a8\u6001\uff0c\u5e76\u786e\u5b9a\u4e0d\u540c\u8981\u7d20\u662f\u5982\u4f55\u5bfc\u81f4\u95ee\u9898\u7684\u3002<\/p>\n\n\n\n<h3 id=\"h-fact-based-analysis\">\u57fa\u4e8e\u4e8b\u5b9e\u7684\u5206\u6790<\/h3>\n\n\n\n<p>RCA \u4f9d\u9760\u7684\u662f\u5ba2\u89c2\u6570\u636e\u548c\u8bc1\u636e\uff0c\u800c\u4e0d\u662f\u4e3b\u89c2\u610f\u89c1\u6216\u5047\u8bbe\u3002\u5b83\u5f3a\u8c03\u6536\u96c6\u3001\u5206\u6790\u548c\u89e3\u91ca\u76f8\u5173\u4fe1\u606f\uff0c\u4ee5\u51c6\u786e\u627e\u51fa\u6839\u672c\u539f\u56e0\u3002\u901a\u8fc7\u4f7f\u7528\u53ef\u9760\u7684\u6570\u636e\uff0cRCA \u53ef\u4ee5\u4fc3\u8fdb\u66f4\u4e25\u683c\u3001\u66f4\u53ef\u9760\u7684\u5206\u6790\u8fc7\u7a0b\u3002<\/p>\n\n\n\n<h3 id=\"h-multiple-perspectives\">\u591a\u91cd\u89c6\u89d2<\/h3>\n\n\n\n<p>RCA \u9f13\u52b1\u591a\u65b9\u5229\u76ca\u76f8\u5173\u8005\u548c\u591a\u89d2\u5ea6\u53c2\u4e0e\u5206\u6790\u8fc7\u7a0b\u3002\u4e0d\u540c\u7684\u4e2a\u4eba\u6216\u56e2\u961f\u53ef\u80fd\u62e5\u6709\u4e0e\u95ee\u9898\u76f8\u5173\u7684\u5b9d\u8d35\u89c1\u89e3\u3001\u7ecf\u9a8c\u6216\u4e13\u4e1a\u77e5\u8bc6\u3002\u901a\u8fc7\u7eb3\u5165\u4e0d\u540c\u7684\u89c2\u70b9\uff0cRCA \u6709\u52a9\u4e8e\u5168\u9762\u4e86\u89e3\u95ee\u9898\u53ca\u5176\u6839\u672c\u539f\u56e0\u3002<\/p>\n\n\n\n<h2 id=\"h-when-to-perform-a-root-cause-analysis\">\u4f55\u65f6\u8fdb\u884c\u6839\u6e90\u5206\u6790\uff1f<\/h2>\n\n\n\n<p>\u5f53\u7ec4\u7ec7\u6216\u4e2a\u4eba\u5e0c\u671b\u4e86\u89e3\u95ee\u9898\u6216\u4e8b\u4ef6\u7684\u6839\u672c\u539f\u56e0\u65f6\uff0c\u5e94\u5728\u5404\u79cd\u60c5\u51b5\u4e0b\u8fdb\u884c\u6839\u672c\u539f\u56e0\u5206\u6790\u3002\u4ee5\u4e0b\u662f\u6267\u884c RCA \u6709\u76ca\u7684\u4e00\u4e9b\u5e38\u89c1\u60c5\u51b5\uff1a<\/p>\n\n\n\n<ol>\n<li><strong>\u91cd\u5927\u4e8b\u4ef6\u6216\u6545\u969c\uff1a<\/strong> \u5f53\u53d1\u751f\u91cd\u5927\u4e8b\u4ef6\u3001\u6545\u969c\u6216\u4e8b\u6545\u65f6\uff0cRCA \u53ef\u4ee5\u5e2e\u52a9\u627e\u51fa\u6839\u672c\u539f\u56e0\uff0c\u9632\u6b62\u4eca\u540e\u53d1\u751f\u7c7b\u4f3c\u4e8b\u4ef6\u3002\u8fd9\u53ef\u80fd\u5305\u62ec\u8bbe\u5907\u6545\u969c\u3001\u7cfb\u7edf\u4e2d\u65ad\u3001\u5b89\u5168\u4e8b\u6545\u6216\u9879\u76ee\u5931\u8d25\u3002<\/li>\n\n\n\n<li><strong>\u6162\u6027\u6216\u53cd\u590d\u51fa\u73b0\u7684\u95ee\u9898\uff1a <\/strong>\u5982\u679c\u95ee\u9898\u6301\u7eed\u5b58\u5728\u6216\u4e0d\u65ad\u590d\u53d1\uff0cRCA \u53ef\u4ee5\u5e2e\u52a9\u627e\u51fa\u95ee\u9898\u53d1\u751f\u80cc\u540e\u7684\u6839\u672c\u539f\u56e0\u3002\u8fd9\u53ef\u80fd\u6d89\u53ca\u5ba2\u6237\u6295\u8bc9\u3001\u8d28\u91cf\u7f3a\u9677\u3001\u751f\u4ea7\u5ef6\u8bef\u6216\u670d\u52a1\u4e2d\u65ad\u7b49\u95ee\u9898\u3002<\/li>\n\n\n\n<li><strong>\u6027\u80fd\u7684\u610f\u5916\u53d8\u5316\uff1a <\/strong>\u5f53\u6027\u80fd\u6307\u6807\u51fa\u73b0\u65e0\u6cd5\u89e3\u91ca\u7684\u53d8\u5316\u65f6\uff0c\u4f8b\u5982\u751f\u4ea7\u7387\u7a81\u7136\u4e0b\u964d\u3001\u9519\u8bef\u6fc0\u589e\u6216\u5ba2\u6237\u6ee1\u610f\u5ea6\u4e0b\u964d\uff0cRCA \u53ef\u4ee5\u627e\u51fa\u6839\u672c\u539f\u56e0\u5e76\u5e2e\u52a9\u6062\u590d\u6027\u80fd\u3002<\/li>\n\n\n\n<li><strong>\u5ba2\u6237\u53cd\u9988\u6216\u4e0d\u6ee1\uff1a<\/strong> \u5f53\u5ba2\u6237\u5bf9\u4ea7\u54c1\u6216\u670d\u52a1\u8868\u793a\u4e0d\u6ee1\u3001\u63d0\u4f9b\u8d1f\u9762\u53cd\u9988\u6216\u62a5\u544a\u95ee\u9898\u65f6\uff0cRCA \u53ef\u4ee5\u5e2e\u52a9\u627e\u51fa\u6839\u672c\u539f\u56e0\u5e76\u63d0\u9ad8\u5ba2\u6237\u6ee1\u610f\u5ea6\u3002\u5b83\u4f7f\u7ec4\u7ec7\u80fd\u591f\u89e3\u51b3\u7cfb\u7edf\u6027\u95ee\u9898\uff0c\u800c\u4e0d\u662f\u4ec5\u4ec5\u6cbb\u6807\u4e0d\u6cbb\u672c\u3002<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-the-3-rs-of-root-cause-analysis\">\u6839\u672c\u539f\u56e0\u5206\u6790\u7684 3 R<\/h2>\n\n\n\n<p>\u6839\u672c\u539f\u56e0\u5206\u6790 (RCA) \u7684 \"3R \"\u662f\u6307\u5206\u6790\u8fc7\u7a0b\u7684\u4e09\u4e2a\u57fa\u672c\u7ec4\u6210\u90e8\u5206\u3002\u5b83\u4eec\u662f<\/p>\n\n\n\n<h3 id=\"h-recognize\">\u8ba4\u8bc6\u5230<\/h3>\n\n\n\n<p>RCA \u7684\u7b2c\u4e00\u6b65\u662f\u8ba4\u8bc6\u5e76\u627f\u8ba4\u95ee\u9898\u6216\u4e8b\u4ef6\u5df2\u7ecf\u53d1\u751f\u3002\u8fd9\u5305\u62ec\u8bc6\u522b\u95ee\u9898\u7684\u8ff9\u8c61\u6216\u75c7\u72b6\uff0c\u4e86\u89e3\u5176\u5f71\u54cd\uff0c\u5e76\u786e\u4fdd\u95ee\u9898\u5f97\u5230\u5fc5\u8981\u7684\u5173\u6ce8\u548c\u8d44\u6e90\u4ee5\u8fdb\u884c\u5206\u6790\u3002<\/p>\n\n\n\n<h3 id=\"h-react\">\u53cd\u5e94<\/h3>\n\n\n\n<p>\u4e00\u65e6\u8ba4\u8bc6\u5230\u95ee\u9898\u6240\u5728\uff0c\u5c31\u5fc5\u987b\u8fc5\u901f\u505a\u51fa\u9002\u5f53\u53cd\u5e94\u3002\u8fd9\u5305\u62ec\u542f\u52a8 RCA \u6d41\u7a0b\u3001\u7ec4\u5efa\u4e13\u95e8\u7684\u56e2\u961f\u5e76\u5206\u914d\u5fc5\u8981\u7684\u8d44\u6e90\u4ee5\u5f7b\u5e95\u8c03\u67e5\u95ee\u9898\u3002\u8fc5\u901f\u505a\u51fa\u53cd\u5e94\u6709\u52a9\u4e8e\u9632\u6b62\u8fdb\u4e00\u6b65\u7684\u540e\u679c\uff0c\u5e76\u786e\u4fdd RCA \u6d41\u7a0b\u8fc5\u901f\u542f\u52a8\u3002<\/p>\n\n\n\n<h3 id=\"h-resolve\">\u51b3\u5fc3<\/h3>\n\n\n\n<p>RCA \u7684\u6700\u7ec8\u76ee\u6807\u662f\u901a\u8fc7\u8bc6\u522b\u548c\u89e3\u51b3\u6839\u672c\u539f\u56e0\u6765\u89e3\u51b3\u95ee\u9898\u3002\u8fd9\u5c31\u9700\u8981\u8fdb\u884c\u7cfb\u7edf\u5206\u6790\uff0c\u786e\u5b9a\u4fc3\u6210\u56e0\u7d20\uff0c\u5e76\u6df1\u5165\u6316\u6398\uff0c\u627e\u51fa\u6839\u672c\u539f\u56e0\u3002\u901a\u8fc7\u89e3\u51b3\u6839\u672c\u539f\u56e0\uff0c\u7ec4\u7ec7\u53ef\u4ee5\u5b9e\u65bd\u6709\u6548\u7684\u7ea0\u6b63\u63aa\u65bd\uff0c\u9632\u6b62\u95ee\u9898\u5728\u672a\u6765\u518d\u6b21\u53d1\u751f\u3002<\/p>\n\n\n\n<h2 id=\"h-conclusion\">\u603b\u7ed3<\/h2>\n\n\n\n<p>\u603b\u4e4b\uff0c\u5bf9\u5404\u884c\u5404\u4e1a\u7684\u7ec4\u7ec7\u800c\u8a00\uff0c\u8fdb\u884c\u6839\u672c\u539f\u56e0\u5206\u6790\u662f\u4e00\u79cd\u6709\u4ef7\u503c\u7684\u505a\u6cd5\u3002\u901a\u8fc7\u5e94\u7528 RCA \u539f\u5219\u548c\u4f7f\u7528\u9002\u5f53\u7684\u6280\u672f\uff0c\u7ec4\u7ec7\u53ef\u4ee5\u6709\u6548\u5730\u8bc6\u522b\u548c\u5904\u7406\u95ee\u9898\u548c\u4e8b\u4ef6\u7684\u6839\u672c\u539f\u56e0\u3002&nbsp;<\/p>\n\n\n\n<h2 id=\"h-communicate-science-visually-with-the-power-of-the-best-and-free-infographic-maker\">\u501f\u52a9\u6700\u4f73\u514d\u8d39\u4fe1\u606f\u56fe\u8868\u5236\u4f5c\u5de5\u5177\u7684\u529b\u91cf\uff0c\u76f4\u89c2\u5730\u4f20\u64ad\u79d1\u5b66\u77e5\u8bc6<\/h2>\n\n\n\n<p>\u60a8\u662f\u5426\u60f3\u8fc7\uff0c\u4e3a\u4ec0\u4e48\u6709\u4e9b\u7814\u7a76\u8bba\u6587\u6216\u6d77\u62a5\u4f1a\u6bd4\u5176\u4ed6\u8bba\u6587\u6216\u6d77\u62a5\u83b7\u5f97\u66f4\u591a\u7684\u6d4f\u89c8\u91cf\u548c\u8ba4\u53ef\u5ea6\uff1f\u5f53\u7136\uff0c\u8d28\u91cf\u5f88\u91cd\u8981\uff0c\u4f46\u8fd9\u4ec5\u4ec5\u662f\u8bba\u6587\u8d28\u91cf\u7684\u95ee\u9898\u5417\uff1f\u4e0d\u662f\u7684\uff0c\u8fd8\u6709\u5f88\u591a\u5176\u4ed6\u56e0\u7d20\uff0c\u6bd4\u5982\u8bed\u8a00\u7684\u7b80\u6d01\u6027\u4ee5\u53ca\u901a\u8fc7\u56fe\u8868\u6458\u8981\u548c\u89c6\u89c9\u6548\u679c\u8fdb\u884c\u5c55\u793a\u7b49\uff0c\u8fd9\u4e9b\u90fd\u5f88\u91cd\u8981\u3002&nbsp;<\/p>\n\n\n\n<p>\u60a8\u8fd8\u53ef\u4ee5\u5229\u7528\u8fd9\u79cd\u89c6\u89c9\u6548\u679c\u8ba9\u60a8\u7684\u4f5c\u54c1\u8131\u9896\u800c\u51fa\u3002 <a href=\"https:\/\/mindthegraph.com\" target=\"_blank\" rel=\"noreferrer noopener\">Mind the Graph<\/a> \u662f\u4e00\u6b3e\u5229\u7528\u6700\u4f73\u514d\u8d39\u4fe1\u606f\u56fe\u8868\u7684\u529b\u91cf\u5e2e\u52a9\u76f4\u89c2\u4f20\u64ad\u79d1\u5b66\u77e5\u8bc6\u7684\u5de5\u5177\u3002\u7acb\u5373\u6ce8\u518c\uff01<\/p>\n\n\n\n<div style=\"height:21px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img decoding=\"async\" loading=\"lazy\" width=\"1362\" height=\"900\" src=\"https:\/\/mindthegraph.com\/blog\/wp-content\/uploads\/2023\/09\/mtg-medical-science.gif\" alt=\"\" class=\"wp-image-29668\"\/><\/figure><\/div>\n\n\n<div style=\"height:21px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"is-layout-flex wp-block-buttons\">\n<div class=\"wp-block-button aligncenter\"><a class=\"wp-block-button__link has-background wp-element-button\" href=\"https:\/\/mindthegraph.com\/\" 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