Here is a hypothetical problem that occurred in our office:The attending physician did not have the lab report available to discuss with the patient upon his/her follow up visit. Here is how we dissected the problem in search of a solution:

Causes of ProblemEquipmentComputer downNetwork downSoftware got a virusEMR version is outdatedEMR cant communicate with LabInterface has bugLab machine is downCentrifuge is brokenTube lost vacuum Wrong needles (non-retractable) ordered

ProcessRules/policies for phlebotomy were not followedTransportation for system is down (Lab Truck blew out a tire)Test not performedPatient didnt keep their lab appointmentNo available appointments left before the doctors appointmentThere was too long wait for Walk-ins

PeoplePhlebotomist called out sickPatient overslept for his/her appointmentLab technician forgot his/her glassesDriver of lab truck lost his cell phone Delay in getting the tire fixed Specimens hemolyzed while truck was stuck on highwayMaterialsNeedles andVacuum tubes specimen collectionBandages and gauzeTourniquetsLabelsEnvironmentDrawing stationLaboratory harborMedical office practiceManagementOffice managerDoctorLaboratory manager

Below is the first step in our fishbone diagram creation. (Please note that we selected this specific fishbone illustration; any available fishbone template can be used for this process.)

We first placed the problem in the fishs mouth. Next, we identified the contributing causes of the problem, and placed them in the boxes.

Then, we applied each issue under the causes of the problem to form the bones of the fish.

Bonefish Diagram Further Reading

http://en.wikipedia.org/wiki/Ishikawa_diagram

http://whatis.techtarget.com/definition/fishbone-diagram

http://www.isixsigma.com/tools-templates/cause-effect/the-fundamentals-of-cause-and-effect-aka-fishbone-diagrams/

http://www.isixsigma.com/tools-templates/cause-effect/cause-and-effect-aka-fishbone-diagram/