Risk, Reward, and Redemption: Root Cause Analysis in Forensic Organizations

摘要

Forensic science service providers are high reliability organizations and must manage their risk to ensure consistent quality. Investigations into unexpected outcomes, even positive ones, provides feedback into a system of continuous quality and improvement: the "why" is more important than the "what" for an organization to learn and grow. These investigations seek the root causes of the outcome and are called Root Cause Analysis (RCA). Various methods of RCA are available from other high reliability industries. The current article offers a method of root cause analysis for forensic agencies that hybridizes typical quality tools (Pian-Do-Act-Check cycle and "5 Whys") with a decision matrix (simple, complicated, complex, and chaotic) to help streamline the process.