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 (causes) in causal factors that its revision or removing caused to prevent the recursion of a situation such as an error when is occurring in a process. The process of root cause analysis is consist of six steps: the beginning of the process, Data collection and mapping information, Identifying the problems, Analyzing Information, Solution Providing, Implementing the solutions (action plans), Writing the report.

Objectives: This research aimed at analyzing the adverse events reported related to blood transfusion in one of the large vicechancellorships of Iran University of Medical Sciences in spring 2018. Methods: This descriptive study was performed based on the eight stages of the root cause analysis (RCA) of healthcare events by the National Authority for Health. For classifi, cation of the considered concerns, the “, classifying nursing errors in clinical management (NECM)”,model, failure classifi, cation, approved by the UK National Health System, and also a creative problem-solving technique were used for determining the improvement solutions. Results: Based on the results, 70% of states of blood transfusion error and blood products were placed in the category of care errors, 10% in the communication category, 20% in the category of implementation errors, and 0% in the category of knowledge and skill errors. A total of 38 infl, uencing factors were identifi, ed for adverse events of blood transfusion, the most cause of the error was associated with organizational factors (18. 4%), and the least reasons for failure were equipment and resource factors (5. 3%). Conclusions: The establishment of advanced systems for the automatic transmission of blood and blood products, due to the lack of proper infrastructure in Iran, is not economically feasible. Therefore, at the level of this deputy, the guideline for managing blood transfusion and blood products in the two areas of "measures required before, during, and after blood transfusion and blood products" and "hemovigilance for physicians" were developed.

This paper proposes data mining-based models to diagnose outage data in distribution power systems. In this work, outage data from a local distribution company is gathered and aligned with weather data. Then, a subset of features is selected to reduce the processing time and simplifying purposes. To increase the fairness of final models and to account for differences in misclassification cost, using a customized cost matrix is proposed. Two decision tree-based modeling algorithms are trained and tested. Results show the ability of the established models to diagnose the root cause of an outage fairly well. In addition, an ensemble of the decision tree-based models is built, which outperforms the other two models in almost all cases. Finally, applications of such models in decreasing outage duration and improving the reliability of the power distribution network are discussed.

A daunting mine disaster took place in 13 May 2014 at Soma and 301 men lost their lives. Brief information about the Eynez coal mine and some of the inherent characteristics of the field in terms of their effects on mining are presented. This paper basically concentrates on the factors that played an important role in the occurrence of this disaster. Progress of mine fire, firefighting, and rescue activities were only given in basics. Mine fire started suddenly without giving any sign at the hearth of the mine. Sudden occurrence of mine fire and start location properties reveal that the root cause of this disaster was probably not directly related to spontaneous heating of coal. analysis of roof caving mechanism, subsidence profiles, production history, and overall conditions in the mine showed that the mine fire most probably started as a result of a sudden caving above the nearby sealed out old production panels. Upon caving, pressure of the gas present in uncaved voids and unconsolidated goaf must have increased and gas must have overflown through abundant cracks towards the mine. Gas exuding under moderate pressure might possibly be ignited by a non-ex-proof belt conveyor drive motor starting the mine fire.