On April 30, 2010, following a 10-day FDA inspection of a U.S. manufacturing facility, 43 name-brand over-the-counter (OTC) children’s’ liquid medications were voluntarily recalled. Although there have not yet been any reported adverse events associated with the recalled medication, the impact of the issue has been far-reaching.
There is the potential (although believed to be remote) for an impact to consumer health, which is an impact to the safety goal. Additionally, the drugs were recalled for not meeting required quality standards, which can also be considered an impact to the safety goal. The product recall, which encompassed 1,500 lots of 43 products, is an impact to both the customer service and property goal. The cost of this recall has not yet been estimated. The manufacturing facility is on hold, which is an impact to the production goal. Lastly, the time and costs associated with the investigation to determine what went wrong is an impact to the labor goal. We can record these impacts to the goals in the outline (Step 1).
Once we’ve completed the first step, we move on to the root cause analysis, or Step 2. We begin the analysis with the impacts to the goals and ask “Why” questions to complete the Cause Map. Because the FDA’s investigation report has not yet been released, the Cause Map we have so far is very basic. Essentially, the recalls occurred because unacceptable product was released to consumers. It was released because the finished product met testing requirements. However, it was unacceptable because it did not meet quality standards, because of contamination in the raw materials that were used. At this point in the map, we run into more questions. More detail can be added to this Cause Map as the analysis continues and more information is released. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.
A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. View the investigation by clicking on “Download PDF” above.