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Describe your tool/method/skill: Fishbone diagram

Developed by Dr. Kaoru Ishikawa, a renowned Japanese quality control expert, the fishbone diagram serves as a structured approach to root cause analysis for a specific problem or issue (Loredana, 2017). According to Suárez-Barraza and Rodrguez-González (2019), it has a visual depiction that resembles the skeleton of a fish, with the issue or effect located at the head of the "fish" and potential causes spreading out like the vertebrae in the spine.

To create a fishbone diagram, the process typically begins with a clear definition of the problem or effect to be addressed. This issue is placed at the head of the diagram, serving as the focal point of the analysis. Next, a horizontal line extends from the head, representing the backbone of the fish, which acts as the main structure for attaching the causes (Liliana, 2016). The diagonal lines connecting the major groups of potential causes to the spine include processes, people, equipment, materials, and the environment. Under each major category, lists of potential causes are represented as smaller branches extending from the major category lines ((Harel et al., 2016).

Once the potential causes are listed, teams analyse and prioritise them to determine the most likely root causes that need attention. After identifying the key causes, action plans are developed to address each, which may involve process improvements, policy changes, training, or other corrective measures. Continuous monitoring and measurement are essential to track the progress of these actions and ensure that they effectively address the problem and yield the desired results (Brook et al., 2015).


Brook, O. R., Kruskal, J. B., Eisenberg, R. L., & Larson, D. B. (2015). Root cause analysis: learning from adverse safety events. Radiographics35(6), 1655-1667.

Harel, Z., Silver, S. A., McQuillan, R. F., Weizman, A. V., Thomas, A., Chertow, G. M., & Bell, C. M. (2016). How to diagnose solutions to a quality of care problem. Clinical journal of the American Society of Nephrology: CJASN11(5), 901.

Liliana, L. (2016). A new model of Ishikawa diagram for quality assessment. In Iop conference series: Materials science and engineering (Vol. 161, No. 1, p. 012099). IOP Publishing.

Loredana, E. M. (2017). The analysis of causes and effects of a phenomenon by means of the “fishbone” diagram. Ann Econ Ser5, 97-103.

Suárez-Barraza, M. F., & Rodríguez-González, F. G. (2019). Cornerstone root causes through the analysis of the Ishikawa diagram, is it possible to find them? A first research approach. International Journal of Quality and Service Sciences11(2), 302-316.

Realted Topic:- University of Wollongong

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