Author Archives: Barb Phillips
On November 19, 1984, a series of explosions caused one of the deadliest industrial accidents in the history of the world. The explosions occurred at a storage and distribution facility for liquified petroleum gas belonging to Petroleos Mexicanos. It is believed that the explosion started with a gas leak which caused a plume that grew large enough to be transported by the wind and reach a flare pit where it ignited.
The explosions and fires demolished most of the town of San Juan Ixhuatepec, and it is estimated that up to 600 people died and 5,000 – 7,000 people suffered severe injuries. The fire created such an inferno that most corpses were reduced to ashes, making it hard to determine who perished.
Learn more about the disaster.
When something catastrophic happens, companies often discover a series of errors and process flaws that were present all along. Advanced root cause analysis skills can help you uncover these error and flaws. Visit our training page to find a course near you:
Surveys about fear have revealed that we fear public speaking more than death. That’s why there is a joke that goes something like, “If you are at a funeral, it’s better to be in the coffin than the one delivering the eulogy.”
However, there are many things we can learn about public speaking from the masters. Even better, there are many very simple techniques that will captivate the audience every single time.
Take, for example, the pause:
Pause for two or three seconds and the audience assumes you lost your place. Pause for five seconds and the audience begins to think the pause is intentional… and starts wondering why.
Pause for ten seconds and even the people who were busy tweeting can’t resist glancing up.
These days, if you can get someone to look up from his or her phone during your presentation, you’ve pretty much won at public speaking.
Learn four more ways to be a better speaker from Jeff Haden:
The media debate about Ebola is subtly shifting from how to stop the spread of this horrific disease to finger pointing. How do we stop the blame game?
A recent analysis & opinion column (Reuters.com), “Why Finger Pointing about Ebola Makes Americans Less Safe,” suggests:
With Ebola, root cause analysis is going to be key to avoid mistakes in the future, but this will require a culture where it is safe to admit to errors.
Read the opinion here:
And let us know what you think by commenting below. How can the healthcare community create a culture where workers are not afraid to self-report mistakes? Do you think root cause analysis is key to stopping Ebola?
What is the key intervention for preventing 6,600,000 death? You may be surprised by this solution, which is also the key intervention for reducing Ebola outbreak. It is the simple act of handwashing with soap. Invest 12 minutes of your time viewing this video and learn about the power of handwashing.
Did you know that TapRooT® is recognized worldwide as a premier “knowledge broker”? Stay in the know with relevant root cause analysis tips by joining our weekly email list:
Some recent tips include:
Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry: (View video.)
Missed Opportunities: (Read post.)
What Makes a World Class Root Cause Analysis System? (View video.)
Do you wish you could use your LinkedIn profile to find a new job or network to get more business for your current job? Here are 3 tips that will optimize your personal profile and make these wishes more likely to come true.
1. Add a profile picture (it will make your profile 7 times more likely to get noticed). Don’t just upload any profile picture, choose a clear photo of your face that is appropriate for business networking.
2. Get recommendations. LinkedIn offers tools that make it so easy to request recommendations. Go to your profile and click the dropdown menu next to “Complete your profile.” Choose “Ask to be recommended,” and you will be guided through a series of prompts to complete your first recommendation request. Painless!
3. Customize your profile URL. Customize your URL with your name to help search engines identify you. (Learn how).
Why not take ten minutes to invest in your career development? A few tweaks to your LinkedIn profile will help you become more visible and lend greater credibility to your professional image.
Is your company trying to reduce costs associated with excessive overtime? Circadian® 24/7 Workplace Solutions recently released an infographic with 5 shift work tips on how to manage overtime.
View the infographic here: http://www.circadian.com/blog/item/38-5-shift-work-tips-how-to-manage-overtime.html#.VDQyeCldVQX
On October 4, 2010, toxic sludge leaked from a metal refinery in Hungary. Over 100 people were injured, many suffering burns, and at least ten deaths were attributed to the disaster. The company was fined $647 million for environmental damage (Read article and view dramatic photos on The Guardian).
Learn how TapRooT® Root Cause Analysis can help you avoid injuries, deaths and costly fines. (Click here to learn more.)
A recent article in the The Washington Post listed some tips for getting caught up and I really liked it because the author pointed out:
“Rather than worrying about whether we have caught up, which can lead to feelings of inadequacy, we can try some of the following activities to restore ourselves and feel better about what we are accomplishing.”
Are we ever really caught up? Maybe it’s time to change the mindset to noticing what we are accomplishing instead of focusing on what we haven’t finished yet. It may be more motivating and more productive to think this way.
Feel better about what you are accomplishing and read 10 tips written by Joyce E. A. Russell here:
On September 3, 1991, a fire broke out at Imperial Foods Processing Plant in Hamlet, North Carolina after a repaired hydraulic line burst.
Heating gas plumes from a cooking vat ignited hydraulic fluid spreading heavy black smoke throughout the plant within a couple of minutes. Twenty-five workers lost their lives including a route salesman who had been filling food machines in the break room. Fifty-four people were injured.
It was determined that the deaths were caused by smoke inhalation when the workers could not exit the building due to blocked or locked exits. According to the Fire & Rescue Journal, “Hydrocarbon-charged smoke, particularly as heavy as this, is extremely debilitating to the human body and can disable a person with one or two breaths.”
Imperial Food’s owner pleaded guilty to involuntary manslaughter and was sentenced to 19 years 11 months in prison. The victims received a $16.1 settlement. (New York Times.)
In the following video, a visitor films the memorial for all the workers whose lives were lost.
It’s devastating when a workplace becomes a memorial to workers who perished there. Learn best practices to find and fix root causes so this never happens at your facility:
“Treat people as if they were what they ought to be, and you help them to become what they are capable of being.” Johann Wolfgang von Goethe
Imagine for a moment that we actually treated one another with such an unbiased respect and unconditional belief that we were able to elevate each other to be the best we can be. It’s not just a military slogan. It can and does happen. I’ve experienced this kind of respect, belief and positive reinforcement in my own life.
I’ve heard and witnessed many incredible stories of how people, given little chance to live or to walk again, overcame their physical and emotional injuries to lead positive, productive lives. They, in turn chose to “Pass the salt and make a difference in other people’s lives.” One particular story I read about recently, where a man who was barely able to read was given an assignment that required him to not only read, but to speak in public and exhibit leadership skills. (I know from personal experience that man’s greatest fear is NOT standing in front of a crowd and speaking. Man’s greatest fear IS walking (or crawling) through a wall of fire.) The man’s personal transformation was called miraculous. He was told that GOD inspired his assignment, and he took it quite seriously. He became an eloquent speaker and leader and that helped him to prosper in other areas of his life and provided a better life for his family. How can this be done you ask? Glad you did and here are some tips:
Release the prejudice. The first step is we must relieve ourselves of the limitations we place on others. Eradicate (I like the word) negativity about ours and others limitations from our mind and memory; erase the mental models and phrases like, “She’s only” or “He’s always” or “They never,” or “He can’t.” We need to stretch our mind and our imaginations and visualize, “see”, them doing something great or being something great. Change our thought patterns from the negative to think “Just because he (or she) never did that before doesn’t mean that he (or she) can’t. It just means that he (or she) has never tried before because no one really believed he (or she) could.”
“None can be more negative on its impact than the limitation on human resource capacity.” Said Musa
Forget the past. Car windshields are larger than the rear view mirror because it’s far more important to see the ‘highway’ ahead than the ‘road’ travelled. Look where you’re headed, not where you’ve been. Whatever mistakes you and others have made and wherever you and they have failed before, or the horrible way you or they have been treated, leave it go! Those issues are totally irrelevant for today. The past is the past. It’s over! Everyone has a story. Choose to change your mental models. ‘See’ yourself and them as winners, not whiners and treat yourself and others that way. It’s sequential, inside out, not outside in. You and then others. Get your own ‘house’ in order first.
“Life is divided into three terms-that which was, which is and will be. Let us learn from the past to profit by the present, and from the present to live better in the future.” William Wordsworth
Remember your roots. We’ve developed and grown into the person we have become because someone, or in my case, many someone’s, believed in us. It was our parents, mentors, teachers, friends, God, all the above and many others. Along the way, there were (and are) people who believed in us and that belief helped us to believe in ourselves. When we stop, pause and reflect on where we began and where we are now and all those who’ve helped us and believed in us and then apply that same belief in others, the results can be (and are) amazing. Like all meaningful change, it has a beginning and middle but no end. It’s continuous.
“Believe in yourself and stop trying to convince others.” James De La Vega
Use words that encourage and inspire. Positive affirmations. A few examples like, “If I can, you can.” “You will succeed.” “You’re potential is endless.” “You’re more than capable.” “You’re smart and articulate.”
Assist them through the setbacks. I’ve discovered that few things in life have a trajectory that’s straight up. On the contrary, there are many issues from our choices that are often straight down. There are times when we ask, “What am I doing? Am I crazy for trying this? “What was I thinking?” “I should have asked for help?” Don’t let the negative thoughts get in the way. Bring them out. Talk about them with people you trust. Share your thoughts and then dismiss them. Vent! It’s healthy. Then continue with your encouragement and prayers. Caution: prayers work! Be careful for that which you pray. You might just receive it.
Encourage others to play it forward. Regardless of when and where I’m greeted by others, my reply is always, “I’m vertical, take nourishment and play it forward when God provides the opportunities.”
After a goal’s achieved, encourage others (and yourself) to establish and seek more goals and continue that pattern. I believe we have an obligation, or errand to help those around us; those who seek our help and are truly committed and enrolled in the process. What we don’t want to I do is become an enabler and weaken them emotionally, spiritually and physically. When we see others as better than they are or were and help them on their journey of self-realization and self-improvement it is one of the noblest things we can do for others. When they achieve success, it’s a win-win. Many, many others have done that for me and for you too, I suspect and often without us even knowing it. So…”Pass the salt and make a difference in all you choose to do. Make a person, place or thing a little better for your having been there.”
“Correction does much but encouragement does more.” Johan Wolfgang von Goethe
Becky Hammon was recently hired as the first female basketball coach in the National Basketball Association (NBA) by the San Antonio Spurs. She’s played professionally here in the U S and overseas for 17 years and begins her new position as an assistant coach next year.
In the Tuesday, August 12, 2014 edition of “USA Today Sports” an article written by Nancy Armour shares her exclusive interview with female basketball player Becky Hammon. “Even after all these years, Becky Hammon hears the voices in her ear,” she said. “The assistant coach at Colorado State University was constantly on Hammond telling her she was going to be the school’s first All-American. How she was going to do this. How she was going to do that,” she said. In the interview Becky Hammond said, “but when she started speaking all that, she started planting seeds. ’Yeah, maybe. Maybe I could do that if I worked really hard,’ Hammon said. “You have those people speaking really good things in your life and it grows and produces fruit later on,” she said. “But somebody had to initially plant those good seeds.”
”Hope and encouragement, especially hope, is probably one of the greatest things you can give another person,” Hammond said. “I mean, what a gift to allow that person to be able to dream, to be able to say, ‘Why not me?’ ‘Why couldn’t I be the first?’”
“Hope is the thing that perches in the soul-and sings the tunes without the words-and never stops at all.” Emily Dickinson
Life really IS like a roll of toilet paper. The closer to the end the faster it goes. When you leave this life, what will be your epitaph? What do you want others to say about you? How do you want to be remembered? When our time’s up, it’s up. No more make-ups or second chances. So…take time to be the person who others hear in their ears. Tell them how they’re going to do this and how they’re going to do that. Make the choice to become a planter of positive seeds then stand back and watch the ‘plant(s)’ grow. I know it works!!
Non-verbal communication (body language) is significant because it reveals how we feel (sometimes in spite of what we say), and it also reveals how other people feel about us. Most of us are not formally trained in non-verbal behaviors but living in the world has taught us many non-verbal cues informally.
For example, have you ever met someone and felt like you didn’t like them but couldn’t pinpoint why? They may have thrown off negative non-verbal cues that you picked up subconsciously, and that is why you stepped away from the experience feeling like you didn’t like the person. You probably know more than you think you do about non-verbal communication from both positive and negative life experiences, and putting the pieces together will help you become a better communicator.
At the Global TapRooT® Summit we’ve shared best practices for decoding non-verbal behavior which is particularly helpful in incident investigation interviews.
When interviewing others after an accident or incident, it’s very important to gain the interviewee’s confidence and trust to put them at ease and help them remember important details. Today I’d like to share three quick tips on how to improve non-verbal communication that will improve your interviews.
1. Lower your eyebrows. When we relax tension in our faces, the rest of the body follows in relaxation. Close your eyes right now and release the tension in the forehead and brows. Notice how the rest of your body becomes more relaxed. Practice this before your interviewee arrives and your relaxed body language will help your interviewee relax as well.
2. Palms up. When we talk we often gesture with our hands. Palms up sends a message that we have nothing to hide in our agenda, and also conveys that we are open to receiving what the interviewee says. Palms down indicates that we have closed our thinking – it may send a message of conviction – that your mind has been made up about what caused the accident.
3. Don’t overdo it on eye contact. Many people think that constant eye contact is important to communicate effectively, but it can be very intimidating for an interviewee. Make good eye contact but don’t stare. Make eye contact for shorter periods of time releasing your gaze occasionally.
If you want to learn more about effective non-verbal communication, mark your calendar to attend our new 2-day Interviewing and Basic Investigation course, June 1-2, 2015 in Las Vegas, Nevada right before the 2015 Global TapRooT® Summit.
On August 9, 1965, 53 contract workers were killed during a fire at a Titan missile silo at Little Rock AFB in Searcy, Arkansas. The investigation indicated that the fire was caused by a ruptured hydraulic line spraying diesel fluid on a wire, igniting it.
One of the two workers who survived told his story after keeping it to himself and his close circle for 33 years. He was only 17 and had only been working in the silo for two days when the accident happened. He recalled seeing a sign at the site, “206 days without an accident.”
Click the link below to read his account:
Are you relying too much on your good record? Learn best practices in analyzing accidents, incidents, near-misses, equipment failures, operating issues or quality problems:
The Val di Stava dam collapsed on July 19, 1985 when two tailings dams used for sedimenting the mud from a nearby mine failed. The subsequent mudflow caused one of Northern Italy’s worst disasters – 268 lives were lost and 63 buildings and eight bridges were destroyed.
According to The History of Geology:
“An investigation into the disaster found that the dams were poorly maintained and the margin of safe operation was very small. As last trigger of the failure is considered a leak of water, caused by a pipe in the upper dam, used to drain water, which had been bent by the weight of sediments. The increasing water pressure of the bunged up dam, in combination with the water saturation weakening the sediments of the dam wall, caused probably the collapse.”
National Hazards and Earth System Sciences published a report indicating that effective regulation may have prevented this disaster.
What do you think? Leave your comments below.
Chris Gaborit, Managing Director at The Learning Factor, created this video to inspire us to discover our passion and purpose and to achieve our greatest performance. Invest five minutes of your life to become inspired!
Lost respect at work? A few tips on how to regain it.
Many of us have experienced it. First, it’s the extended lunches. Then, you notice the late arrivals and unexcused tardiness. Next, are the assignments that aren’t finished, not completed to specifications or seem to take longer than usual to complete. When you confront the employee(s) all you hear are the excuses: “I can’t” or “That’s not my job.” That’s your first outward example of a “Wake-Up Call” that you’re a leader who’s losing credibility and respect … and you figure out you need to make some changes … and quick.
“He that is good for making excuses is seldom good for anything else.” Benjamin Franklin
In every situation of which I’m familiar, regardless of the type of organization, when employees respect and trust their leaders and feel that respect and trust in return, you have a highly motivated employee(s) who are more creative and energized people who actually look forward to come to work every day. Every employee I’ve known, myself included, places a high value on a leader they can trust and respect and from who they can learn. That respect and trust is an important, intangible asset. You can’t touch it or taste it but you CAN feel it and you know when it’s there and when it isn’t in the workplace and in the relationship.
“Leadership is one who knows the way, goes the way and shows the way.” John Maxwell
If you need to re-establish yourself as a true leader who your employees and your leadership trust and hold in high esteem, here a few tips to help you reestablish that trust:
Appearances matter. Sometimes dress codes are taken to the extreme. It does seems odd to wear business attire when the company’s culture is T-shirts and jeans. Upgrade you attire to gain respect at work. Develop an approachable presence and internally and externally polished image. Look good … feel good. Don’t over spray with cologne or perfume to mask ‘stuff.’ You know what I’m talkin’ about.
“Appearances rule the world.” Fredrich Schiller
Establish regular feedback sessions with your staff. Leaders who don’t communicate regularly and openly with their staffs miss the opportunity to discover what people really think. Regular feedback sessions not only demonstrate how much you value their opinions, but you’ll also receive an objective, real-time assessment of their strengths and those areas that may need to improve.
“Mentoring is a brain to pick, an ear to listen, and a push in the right direction.” John C. Crosby
Trust demonstrated is trust earned. Empower your staff to own it. Encourage calculated risks and make sure they know you’ll have their back if things don’t turn out as expected. Trust them. Walk-The-Talk.
Watch your “pie hole.” Words and actions have consequences! If you believe from your intuition and subtle feedback from your staff that you do receive less respect at work, it may because your actions don’t mirror your words and vice versa. Words we use must always be respectful and clean, most discreet when it comes to personal issues and never openly criticize your staff. Praise in public and provide constructive feedback in private … with the door ajar … and with another person in the room with you … it is what it is … lesson learned.
“Good actions give strength to ourselves and inspire good actions in others.” Plato
Know when to be quiet. Emotional tirades earn fear but no respect. Unless you’re one of those (all too many ‘leaders’) who ‘lead’ by fear, tirades may make you feel better but they do little to change the culture at work, except to make it even more toxic. Egg shells are designed to be broken at home, not walked on at work. Address sensitive work issues at a private, one-on-one level not letting your ego show and proudly exclaiming them at meetings and embarrassing the employee(s). The opposite philosophy is always true. When you praise and thank people for a job they’ve done well, always do that in public. Be generous and genuine.
“Nothing strengthens authority more than silence.” Leonardo da Vinci
Share your knowledge. As a leader, you have a great opportunity to be a teacher and mentor. The examples include work directly with a staff member to improve their written and/or oral communications or indirectly, when you lead by example. When you share your information and mentor others, you train and educate the organization’s future leaders.
“The teacher who is indeed wise does not bid you to enter the house of his wisdom but rather leads you to the threshold of your mind.” Khalil Gibran
Suspend assumptions. Place any preconceived ideas you may have aside and really listen to an employee’s proposal with an unbiased perspective. If a conflict does arise, remain objective, stay fair, don’t show favoritism and provide the opportunity for everyone to succeed.
Remain involved. Said another way, get out from behind your desk and walk around the organization. Make the time and take the time to ask questions and then listen. Chat informally at company functions like an office party or get-togethers after work. Get to know your staff and encourage them get to know you. Leave your rank at work.
Be transparent. We’ve heard this many times of late. Change comes in many forms and many ways; some when not expected. When change is on the horizon, remain engaged with your employees and keep them in the loop as much as you can.
“One man’s transparency is another man’s humiliation.” Gerry Adams
Establish the limits (Boundaries). If after your efforts to change the dynamics and your team or staff remain disrespectful, or if one or two apples still spoil the barrel and rather increase their disdain, it’s time for more drastic action. Tell them their behavior is unacceptable and won’t be tolerated. Explain the importance to maintain a civil level or respect and trust in the workplace. Then … document, document, document. This should be done as a routine practice, anyway. Then, at quarterly, semi-annual and annul performance reviews the behavior was documented and at your disposal.
“The difference between stupidity and genius is that genius has limits.” Albert Einstein
It’s never easy to regain trust and respect at work and with your friends and your family once those values have been lost. A good start is to have a high regard and respect for you … to love yourself but not be in love with yourself. Have that same regard and trust for your team and employees. Want to gain or re-gain trust and respect? Be trustworthy and respectful first. It’s inside out, not outside in … radiate and project what you want and expect outwards. This will most often encourage them to reciprocate.
“Men are respectable only as they are respected.” Ralph Waldo Emerson
“You should bring something into the world that wasn’t in the world before.
It doesn’t matter what that is. It doesn’t matter if it’s a table or a film or gardening – everyone should create.
You should do something, then sit back and say, I did that. ~ Ricky Gervais
This video is a hilarious because it highlights everything that can (and often does) go wrong on a conference call. Are conference calls productive? What do you think?
We all know that stress is bad for us both physically (increasing our risk for disease), and mentally (that overwhelming feeling). But in spite of our knowledge, did you know that we can actually become addicted to stress?
Who is at risk?
Type A personalities – those who operate at a maximum speed and aspire to achieve large goals. (Learn more.)
Type D personalities – those who struggle with negativity, depression, anxiety, stress, anger, and loneliness. (Learn more.)
So, how do you know if you’re addicted to stress?
Research tells us that moderate amounts of stress are fine, even desirable, because it boosts our focus and energy. So don’t automatically label yourself. If you are effectively managing your life and thriving under stress, it does not qualify as an addiction. The problem is when we wake up an internal craving for it, just as an alcoholic or drug addict would crave a high. If your life feels out-of-control, and in spite of your best efforts, you are not getting things done, you may be addicted to stress.
Whether you’re addicted or carrying a healthy load of stress, don’t forget to balance your days with stress reducing activities.
And enjoy a happier, more productive lifestyle.
I have a habit of buying a bouquet of flowers for my office whenever I go grocery shopping – a guilty pleasure. Today, I read research that makes me feel a little less guilty. Did you know that exposure to flowers can:
- reduce anxiety, negativity and depression
- promote creativity (a University of Exeter study noted a 45% increase!)
- enhance innovative thinking
- increase productivity
One study indicated that people feel happier and had more energy after looking at flowers first thing in the morning. Flowers may even have a positive impact on memory. If you have a green thumb, research suggests that growing your own plants increases the benefits, improving health, well-being, and life satisfaction.
These benefits were noted in women and men, the young and the elderly.
Today’s job fair leans more toward virtual than the meet & greet at the Convention Center that was popular before social media.
Here is an infographic from by MBAOnline.com that breaks down how may people have found jobs on the social network:
Is it time to clean up your social media presence?
It may be where you find your next big career opportunity. Sometimes we forget just how many people can see what we are putting online and this can work for or against us.
Here are 3 tips for cleaning up your digital footprint.
1. Search yourself. Put your name, in quotations, into three search engines and see what comes up. Is there anything you want to take off the internet? You may find old social profiles you no longer use (Myspace anyone?) that you are ready to delete.
2. Review the privacy settings. One thing to be sure of about the big three (Facebook, Twitter and LinkedIn) is that their policies will change. You may have set privacy setting years ago and never revisited. Take some time to do so and ensure that the right people are seeing your posts.
3. Always use a flattering profile picture. You may have your Facebook privacy set so that only your close friends and family can see you, but if your profile is searchable, potential employers can look you up online and still see your profile photo, so choose wisely.
What do you think? Have you ever received a career opportunity on social media?
Baseball celebrates a .400 batting average, Healthcare fires a .900 surgery average! If your doctor had a trading card, what would your doctor’s stats say?
Check out this video of Dr. Brian Goldman, Emergency room Physician at Mount Sinai Hospital in Downtown Toronto for over 20 years. He is also a well-known medical journalist and host of CBC Radio’s White Coat, Black Art. He is the author of The Night Shift in which he shares his experiences of witching hours at Mount Sinai, as well as other hospitals he has practiced at over his long career. He talks about the mistakes he has made in his practice. He tells us what he has learned about being transparent with his failures as a way to be sure that he learns something from them. As people in the workforce, in any industry, we need to realize that we are not perfect. We must realize that we make mistakes and we need to look at those mistakes to make sure they do not happen again. That is where TapRooT® comes in to help find the Root Cause of that mistake and learn how to stop it from happening again. We have to redefine how we look at errors. Not as a way to look down on people, but a way to benefit our world by learning from those mistakes.
(This post was submitted by Jordan Harless, Healthcare Research and Development Associate, System Improvements, Inc.)
Edwin G. Foulke, Jr. presented “Achieving Operational Excellence and Profitability Through Safety” at the 2014 Global TapRooT® Summit.
If you were there, here is a .pdf of the presentation to refresh your knowledge, and if you missed it, you may enjoy learning some great tips:
I really enjoy reading the “Career Curveballs” channel on LinkedIn. I think learning from another person’s mistakes and hard times are as valuable as hearing from the experts. I recently read “The Most Important Mistake of My Life and How You Can Make Yours” by Judd Marcello which was posted on his website and then featured in the LinkedIn Career Curveballs channel.
This part of the article really stood out:
“People often talk about and write about purpose as if was a thing, e.g. tradesman, artist, developer. I have come to realize that for me it is not a thing, but my context. It is what I am here to do. It is within this context that I make career and life decisions, let alone my day-to-day micro decisions. When I make my next career move the decision criteria will be based primarily on whether or not I will be in the best possible position to apply my strengths in order to make a positive lasting impact on the business and the people involved. That is what I am here to do.”
You can read the article in its entirety here: The Most Important Mistake of My Life and How You Can Make Yours
What do you think? Have you ever made a mistake that helped to change the course of your career in a positive way?
On June 1, 1974, 28 employees were killed and 36 injured during a massive vapor cloud explosion at the Flixborough Works of Nypro (UK) Limited. Additionally, hundreds of people offsite were injured and over 1,800 houses and 167 businesses in the surrounding communities were damaged.
The investigation indicated that the explosion may have been caused by a failure of a temporary piping modification. Thirty tons of cyclohexane vapor were released when the piping failed, and when the vapor cloud found an ignition source, the energy released was equivalent to about 16 tons of TNT.
Open the .pdf of the Report of Court of Inquiry:
Learn how to lead your team in root cause analysis and avoid major incidents where lives are lost and workers and community members are injured:
The following post was submitted by Jordan Harless, our Healthcare Research and Development Associate.
In the root cause analysis world, we look back to find out what went wrong after a healthcare error or where the process was flawed or broken. The same can be done before an event happens. We look at data and processes and find the ways that the process will break down.
In healthcare the human element is an unavoidable obstacle. If there were no humans in healthcare there would be far fewer errors. Of course no one wants a robot for a doctor. Human errors can come from many sources such as: procedures, training, quality control, communication, management systems, human engineering, and work direction.
If you or someone you know has suffered from a medical mistake, take a look at the article and see if you can find some tips that could have prevented the mistake. Better yet, use these ideas to prevent the next medical error from happening to you.
With so much that can go wrong we as potential patients at some point in our lives, we need to be especially vigilant in reviewing our care/treatment.
If you work at a facility interested in improving patient safety, consider attending a TapRooT® Root Cause Analysis course. Learn all of the essentials to get to the root cause of an incident in our 2-day course: