A new investigation by the Inspector General of the Department of Health and Human Services says that:

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized.

The report also says that:

…even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the ‘adverse events.’

For the whole report, see:


So, only a small fraction of sentinel events are investigated and most of those don’t cause permanent, effective change to prevent future errors.

Sometimes it can be frustrating to be a prophet when those that could make change happen just don’t listen. We’ve been suggesting proven ways to improve sentinel event investigation and performance improvement that could be applied by medical facilities ever sine the 1994 TapRooT® Summit. But only a limited number of healthcare facilities have taken advantage of the lessons they could learn.

The TapRooT® Summit is coming up on February 29 – March 2 and we have a full track devoted to improving performance in the healthcare industry. This isn’t just lessons from inside the industry. Rather, this is a place where healthcare folks can learn from a wide variety of industries and facilities with best practices from around-the-world.

If you are from a healthcare facility that needs to improve (and from the Inspector General’s report, that’s just about every facility) there’s still just enough time to sign up. See: