What’s left in the patient by accident? See this link …
The Agency for Healthcare Research and Quality did a study looking for proven methods of improving patient safety and healthcare outcomes. In that study, results of root cause analyses were used to find targets for improvement, look for effective techniques (proof of improvement), and provide potential areas for developing corrective actions (improvement initiatives).
The report defined root cause analysis several different ways, including:
Page 290: “Root cause analysis (RCA) is a structured analysis technique originally developed for human factors and systems engineering to retrospectively determine the interrelationship of component elements in causing an observed malfunction or accident. It has been adapted for use in medical and health care systems.”
Page 412: “…an in-depth examination of the data to identify factors in the care process that contribute to the errors…”
One comment in the report was:
“Wu examined the use of RCAs in medicine generally, and noted a very wide range of skill in performing RCAs accurately, a lack of best practices in reporting and followup, and the absence of peer-reviewed evidence of the effectiveness of RCAs or their cost-benefits tradeoffs.”
(Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299(6):685-7. PMID: 18270357)
That made me worry.
Were conclusions drawn in the report that were based on faulty root cause analysis?
After all, we have all seen poor root cause analysis done before. 5-Whys that lead to a preconceived result. Fault Trees built to prove a hypothesis (and missing other possibilities). People jumping to conclusions and not considering causes that they don’t understand.
I wondered … “What if the healthcare industry really adopted an effective root cause tool (TapRooT®) and then actually implemented it effectively? … What would happen?”
There’s more to TapRooT® than just sending people to a 2-Day Course.
To get the full benefits from TapRooT®, management must integrate it into their improvement efforts and manage it’s implementation and use.
That’s why we wrote Chapter 6 of the TapRooT® Book. To guide people to what an effective TapRooT® implementation looks like.
Implementation that includes a vision for improvement with a written plan that includes a sponsor, an improvement leader, and trained facilitators and peer reviewers. A plan that includes effective measurement and continuous improvement. A plan that includes management reviews and rewards for investigations and measured improvement success.
Work is required to make root cause analysis successful. If you are in the healthcare industry (or any other industry for that matter) read Chapter 6 and take the challenge to implement TapRooT® effectively at your facility. You’ll then be able to prove that TapRooT® was effective in helping you improve patient safety.
The Agency for Healthcare Research and Quality published a research product that suggested proven ways to improve patient safety. Here were the best methods (strongly encouraged) from the study:
- Preoperative checklists and anesthesia checklists to prevent operative and post-operative events.
- Bundles that include checklists to prevent central line-associated bloodstream infections.
- Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
- Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
- Hand hygiene.
- “Do Not Use” list for hazardous abbreviations.
- Multicomponent interventions to reduce pressure ulcers.
- Barrier precautions to prevent healthcare-associated infections.
- Use of real-time ultrasound for central line placement.
- Interventions to improve prophylaxis for venous thromboembolisms.
For the complete study, see:
Healthcare Scandal in UK – Calls for Major Improvements in Patient Safety and Criminal Prosecution of “Wrongdoers”February 24th, 2013 by Mark Paradies
Here’s a link to one of many stories about the “scandal” at UK hospitals in the Midlands:
The story says that “…up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital.”
Here’s a link to the Executive Summary of the report referred to in the article:
Here’s a page where you can download the entire report:
The reports are extensive and I haven’t yet been able to wade through them (many volumes and 290 recommendations).
Here’s a press conference by the Chair of the Inquiry, Robert Francis QC:
The problems reported certainly do seem shocking. The problems are obviously systemic (generic) and seem to be related to the organization. The call for culture change seems obvious, but how to change the culture will be difficult. The problem for patients is the lack of choice (there is only one NHS) so that patients can’t “vote with their feet” when the standards of care become substandard.
The popular press and political outcry is calling for increased regulation and criminal prosecution of those who violate the rules. This seems close to the standard blame game and may succeed temporarily until the increased scrutiny eventually succumbs to complacency. This seems common in organizations with a monopoly on a certain service or product.
It seems to me that competition from hospitals trying to win additional patients would be the ultimate culture change recommendation. However, it is unlikely that this approach could be taken since the UK has had a single national service for so long.
Being in the UK when the story was receiving so much press, I was constantly being asked about how one would find the root causes of patient safety relayed problems. Of course, I described how healthcare organizations in the US use TapRooT® to investigate sentinel events. In the US, patient safety is becoming a competitive advantage – a way that hospitals may compete for patients.
What does your hospital do to ensure the highest standards of patient safety? Does your root cause analysis find and fix the root causes of patient safety problems? Does your management require advanced root cause analysis and insist on the implementation of effective corrective actions to sentinel events? Can you show the improvement in patient safety through the use of advanced trending tools?
Those interested in improving patient safety should consider attending the Improving Healthcare Quality and Patient Safety Track at the 2013 Global TapRooT® Summit in Gatlinburg, TN, on March 20-22. For more Summit information see:
And for the track’s detailed schedule, see:
and click on the button on the left for the track specific schedule.
For those in the UK, changes as great as those described will be difficult and take tremendous effort. I wish you luck but advise you that thorough advanced root cause analysis and effort will be required on a continuing basis if progress is to be made.
The best way to keep your Valentine’s Day romantic and fun? Make food safety a priority!
A recent article on StateFoodSafety.com notes that the best restaurant to eat in on Valentine’s Day is a clean one. Here are a few of their food safety tips this Valentine’s Day:
- Take note of the dining area and restrooms. If they do not meet cleanliness standards, it’s probably a good sign that the kitchen is also in need of more than just a light dusting. You might consider eating elsewhere for your own safety.
- Only eat foods that are served to you hot. If the food is served to you at a lukewarm temperature, chances are that it was left sitting for too long and has allowed harmful bacteria to multiply.
- Make sure the staff does not touch your food or the tips of your silverware with their bare hands. It’s probably not a good idea to let them sample your drink either.
- Be wary of meat, eggs, oysters, or other raw foods that are undercooked.
- Wash your hands properly before and after eating.
Photo courtesy of NPR.
How many times have you seen a corrective action to “conduct more training”? Why is this often such a poor corrective action?
Unfortunately, even highly-trained people can make mistakes. A recent article illustrates this nicely.
If you haven’t seen the “basketball” video before, take a look at it at the link above.
This article describes how highly-trained radiologists, people who have an incredible eye for detail, can still make glaring errors based on what they are asked to do. It’s a great example of why “training” may not always be the best corrective action.
Interesting article in The Wall Street Journal. The first two paragraphs read:
“When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.”
“The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers.”
The article missed one important advanced but simple idea. Use TapRooT® to find and fix the causes of medical errors and use TapRooT® proactively to prevent them in the first place.
If you don’t know how TapRooT® can help your hospital, you should attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and find out. Start saving lives today!
Monday Accident & NOT Lessons Learned: Under-Reporting of Sentinel Events May Be One More Cause of Failure to Prevent Human Errors in the Healthcare SettingFebruary 20th, 2012 by Mark Paradies
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:
What kills more people in the US than industrial accidents, highway accidents, and airline accidents combined?
Mistakes in hospitals.
The technical term for these mistakes is “Sentinel Events.”
Estimates of the deaths caused vary. We use estimates because there are no accurate statistics on the total number of deaths caused by mistakes in hospitals. There is no national reporting requirement.
Even though there is no national reporting requirement, studies show that despite over a decade of effort to stop sentinel events, no progress is being made. Some studies actually show the problem getting worse. And this problem isn’t unique
WHY NO IMPROVEMENT
Why can’t we improve? There are a number of factors that make improvement difficult:
1. Healthcare Complexity
2. Poor Root Cause Analysis (RCA)
3. Inadequate Corrective Actions
4. Not Enough Management Attention
We will review all of these factors and what we can do about them in the following sections.
Medical practice keeps getting more complex. More complex technology. More drugs with more interactions. More pressure to work faster and be more efficient. The result? More chances to make errors with catastrophic consequences. At the same time, downsizing means less staff to catch errors.
Healthcare complexity calls for increased, proactive application of system reliability and human factors solutions to improve health¬care delivery. Intelligent, resilient design can make complex systems reliable. Plus, staffing needs to be assessed to ensure adequate coverage to apply error-catching activities.
POOR ROOT CAUSE ANALYSIS
After a decade of using RCA to analyze sentinel events, the lack of progress indicates a failure of healthcare root cause analysis.
What’s wrong? A majority of healthcare facilities use inadequate RCA systems including fishbone diagrams, 5-Whys, and healthcare derived root cause checklists. These “simple” techniques are inadequate to analyze complex healthcare sentinel events.
Not only are the RCA systems inadequate, the RCA training is also inadequate. People are assigned to investigate healthcare sentinel events with little or no training. They are lucky to attend a free one to eight hour session provided at a professional society meeting or sponsored by an insurance provider.
But healthcare investigators face another factor that makes root cause analysis even more difficult: BLAME. More than your everyday blame that comes with every accident. Medical malpractice seems designed to make people less open – less willing to cooperate wholeheartedly with investigators.
Furthermore, doctors who are independent contractors are naturally suspicious of investigators who seem to question their judgment and put their credentials at risk. Is it any wonder that we haven’t made progress?
Despite some of the factors that are difficult to address, picking an advanced root cause analysis system and getting people trained shouldn’t be hard. After all, there is TapRooT®!
The TapRooT® System was designed to be used for simple and complex investigations. It has been applied successfully in healthcare settings and has improved performance of complex systems. The 2-Day and 5-Day TapRooT® Courses have been customized for on-site training of healthcare investigators to help them with demanding investigations. Problems solved!
POOR CORRECTIVE ACTIONS
Inadequate root cause analysis is just the start. Typically, we see the weakest corrective actions applied to prevent repeat sentinel events.
Those familiar with the terminology “hierarchy of controls” applied in industrial and process safety may know what I am pointing out. Healthcare corrective actions often include the application of new standards that depend on human reliability. When these fail, investigators recommend some of the “re” corrective actions, including: re-train, re-mind, and re-emphasize (discipline).
But these are the weakest possible corrective actions (see pages 127 -129 in your 2008 TapRooT® Book.) More effective corrective actions include another type of “re” corrective action. Removing the hazard or the target. Or, re-engineering the process to improve system reliability and decrease human error without adding additional tasks for people to cope with.
These types of corrective actions and more are the result of a TapRooT® investigation when investigators apply the suggestions in the Corrective Action Helper® and apply Safeguards Analysis as part of the development of their solutions.
One might say that the cause of all the previous problems is inadequate management attention to performance improvement at healthcare facilities. Part of this inattention can probably be attributed to the fact that most healthcare administrators aren’t trained in advanced performance improvement techniques. Even the few who have had Six Sigma training don’t know about advanced root cause analysis and, therefore, don’t know about the action they could take to make performance improvement happen.
Plus, hospital administrators need to become more involved in the analysis, review, and approval of sentinel event investigations. Involvement can bring them face-to-face with the challenges people are experiencing in the field. Trained managers reviewing a SnapCharT® can see beyond blame to real action to improve performance. They can see their contribution to errors that come from understaffing and fatigue. They can become a knowledgeable part of the team fighting sentinel events.
SIMPLE PLAN TO IMPROVE
Each day, hundreds of lives are lost because we haven’t won the battle to defeat sentinel events. Don’t wait for the entire healthcare industry to wake up to the problems and solutions. Don’t wait for regulatory requirements to force your facility into action. Start today with the tools that are at hand.
1. Bring the message to management. Get them involved. They should feel that EVERY sentinel event at their facility is a personal failure to address the causes!
2. Adopt an advanced root cause analysis system – TapRooT® – including the latest root cause analysis software and database to help you learn from small incidents to prevent major sentinel events.
3. Get the training that your facility needs in root cause analysis. This includes training for hospital administrators, staff, and your performance improvement experts.
Start with a customized 2-Day TapRooT® Course for senior management. Follow that with a 2-Day TapRooT® Course for those who are frequently involved in sentinel event investigations and a 5-Day TapRooT® Course for those who facilitate sentinel event investigations.
4. Once you complete steps 1-3, you are ready to start continuous improvement efforts. Start by attending the TapRooT® Summit healthcare track to find out what other leaders in the field of healthcare are doing to continue improvement efforts.
Don’t wait. People are dying waiting for improvement to occur. Start today!
(Reprinted by permission from the February Root Cause Network™ Newsletter, Copyright © February, 2012)
Healthcare Quality, Patient Safety, and Sentinel Event Best Practices Track at the 2012 Global TapRooT® SummitJanuary 4th, 2012 by Mark Paradies
Are you involved in performance improvement efforts in the healthcare industry? Then you should be planning to attend the 2012 Global TapRooT® Summit Track titled:
Healthcare Quality, Patient Safety, and Sentinel Event Best Practices
Most conferences about improving patient safety, healthcare quality, and reducing sentinel events are strictly organized by and attended by healthcare professionals. This provides good sharing of best practices within the healthcare industry, but does not provide networking or benchmarking outside the healthcare industry.
The TapRooT® Summit provides both in-industry networking/benchmarking and cross-industry/cross-functional networking/benchmarking. Here’s one healthcare industry patient safety professional talking about her experience at a previous Summit:
(.wmv format. Click above to play)
But what about the 2012 Global TapRooT® Summit? There are several sessions at the 2012 Global TapRooT® Summit that have a strictly healthcare focus:
- What does increasing expectations for healthcare quality and patient safety mean to your improvement efforts?
- Response lessons learned from the Joplin Disaster.
- Using electronic medical records to improve healthcare quality and patient safety.
- Using Baldrige criteria to achieve performance improvement.
These provide opportunities to network and benchmark with healthcare professionals.
Plus, there are also sessions that span industries and disciplines:
- Criminal prosecutions of accidents.
- Developing a fatigue risk management plan.
- Positive Contributions in facilitation and management interactions.
But that’s not all. The Keynote Speakers also provide lessons learned and best practices that cross industries.
For example, Astronaut Ken Mattingly, of Apollo 13 fame, talkes about Lessons Learned from Apollo 13 and Space Shuttle Operations.
And Dr. Beverly Chiodo talkes about Character Driven Success and how it can help your improvement program.
Also, there is a panel discussion of senior managers (Gerry Migliaccio, Senior VP at Pfizer; Vicki Hollub, President & General Manager of OXY Permian CO2 Business Unit; and Zena Kaufman, Divisional Vice President of Global Pharmaceutical Operation at Abbott Laboratories) who will discuss “What Does Senior Management Want from Incident Investigations and Root Cause Analysis?”
This is just a sample of the sessions, for the complete TapRooT® Summit schedule, see:
I know you will find the information you take home motivational and valuable. That’s why we provide the following Summit guarantee:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.
Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.
Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.
It was a pleasure to teach and work with this group personally in Hyderabad, India.
If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February. Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.
Go here to register for the 2-day http://www.taproot.com/courses.php?d=1709&l=1
See the public courses and root cause articles for India:
A study of 244,388 death certificates issued from 1979 to 2006 conducted by a doctor at the University of California, San Diego, and published in the Journal of General Internal Medicine showed that fatal medication errors increased by 10 percent in July in counties with teaching hospitals.
Why might this be?
Because many new residents (interns) arrive from universities in July.
New interns don’t have experience, don’t know who does what, are learning what it is to work in a hospital, and, especially in the past, may work really long hours.
David Wenner of The Patriot-News wrote about the problem and some comments by different hospital safety professionals and doctors in an article titled: “Hospital take steps to reduce errors among medical residents.”
What can you do as a patient?
First, check your medications closely.
Second, wait to get sick (or be hospitalized for any reason) until September when the new residents will be more seasoned!
The posting says:
“In this position, you’ll help oversee the design, planning and coordination of our Root Cause Analysis Program, which is focused on the investigation of patient safety issues. Responsibilities include recommending and coordinating error reduction efforts to minimize safety issues and risk within our healthcare system; helping facilities integrate system design improvements using human factors engineering principles; identifying and addressing barriers to the implementation of safety-enhancing practices; and conducting educational presentations that facilitate the understanding and implementation of patient safety within the organization.”
For more information, see:
Very sad story:
Many times when we think of the cost of incidents we think in terms of dollars. But let us never forget the human cost as well. One mistake can affect the lives of many families.
Dr. Atul Gawande at Brigham and Women’s Hospital and several associates developed this “Checklist for Checklists” for use at hospitals…
Great stuff. Check out his web site at:
This was the scene at Eric Cropp’s sentencing hearing…
Hear him talk about the mistakes he made and the criminal prosecution at the TapRooT® Summit.
How Much Do Errors Cost at Your Company? In the Healthcare Industry in the US, the answer is $17 BILLION Dollars!April 26th, 2011 by Mark Paradies
Here’s the article that the number above comes from:
Do you know the answer for your site/company?
If you don’t know, how do you judge how much you should be spending to improve performance?
By the way … how much has the healthcare industry progressed since the picture above in the technology of preventing human errors?
Alcohol or Juice?
Interesting article today titled: “Restaurant to retrain staff after mixed-drink mixup”
On Friday, Taylor Dill-Reese went to an Applebee’s in Madison Heights, Michigan, where — among other things — she ordered her 15-month-old son Dominick an apple juice.
What the little boy apparently got instead was a margarita. His mom told WDIV-TV that she only realized something was wrong when Dominick “kind of laid his head on the table and dozed off a little bit and woke up and got real happy.”
The little boy reportedly began hailing strangers, too.
According to the article the restaurant stated, that it would begin to serve apple juice to children only from single-serve containers at the table and would “retrain all severs on our beverage pouring policy, emphasizing that non-alcoholic and alcoholic beverages must be stored in completely separate and identified containers.”
…. for our TapRooT® trained investigators, can you think of any other root causes than training?
See the story here:
Monday Accident and Lessons Learned: What Can Happen When Management Doesn't Demand Complete Root Cause Analysis and Follow Up with Effective Corrective ActionsJanuary 24th, 2011 by Mark Paradies
Watch this video …
Job Opening: Salt Lake City, UT – University Hospital – Quality Specialist – Needs Root Cause Analysis SkillsJanuary 16th, 2011 by Mark Paradies
Ever thought about volunteering to be a test subject for medicine….. would you be concerned if you were in phase 1 of a new drug trial?
Listen to this pod cast where the standard practice become a practice because no one had become very ill until this study. Each reinforcing non-injury becomes the reinforcement that this must be a good process.
Select the link below to listen.
What do you do with unexplained discrepancies? FDA uncovers more problems at J&J Fort Washington plantDecember 16th, 2010 by Chris Vallee
“In an inspection report released late on Wednesday, the Food and Drug Administration said a recent visit uncovered multiple quality control problems, including a failure to properly handle customer complaints.”
“Inspectors also found “a failure to thoroughly review any unexplained discrepancy” in batches of products and a lack of proper record keeping, according to the report from an inspection that ran from October 27 to December 9.”
The Washington Plant is closed and the article reports that J&J has continued making improvements. The question is whether the handling of unexplained discrepancies is unique to this industry?
In the US Air Force we named it CND, “Could Not Duplicate”; A CND could only be signed off in the aircraft forms by the appropriate personnel. If a CND occurred three times on the same aircraft, the aircraft was grounded.
What is your Industry Rule? (more…)
RCA in India: Do not miss the February 2011 5-Day TapRooT® Advanced Root Cause Analysis Team Leader TrainingDecember 2nd, 2010 by Chris Vallee
Look closely into India until you get to Mumbai. What do you see?
A 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course Open to all companies; similar to the New Delhi Onsite Course shown below held for BW Fleet Management.
1. You get the benefit of our course in India without needing 10 of your people trained at the same time.
2. You do not have to fly your India based employees to another country to be trained.
3. If you are one of our international customers, you do not have send one of your trained investigators to India to complete an Investigation for defects, incidents or sentinel events.
4. Because the students will receive individual software to document their findings, you will receive a consistent report.
Register today to make sure your employee does not lose a seat in the course.
With so much recent interest from India based companies to hold an onsite course in India, we decided to hold a possible public course February in Mumbai.
Companies in India new to TapRooT® are not always ready to set up an onsite class for 10 or more employees until they see what they can do with what they learn. With enough interest and commitment from you, we will have a 5-day public course.
Please contact firstname.lastname@example.org or email@example.com and let us know how many employees you want to send to the course.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
Description: Learn all the TapRooT® tools, and also many advanced skills that a Team Leader needs to collect information, analyze root causes, and develop effective fixes that will help your company improve performance.
Course Fee: $2,395 USD plus GST/VAT
3 or more attendees, each save:-$100
Fee Includes: Includes TapRooT® single user software, TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.
Who Should Attend: Environment, Safety, and Health Managers Quality Managers, Hospital Risk Managers, Hospital Quality Assurance Professionals, Equipment Root Cause Experts, Governement Regulatory Investigators (MSHA, OSHA, EPA, UK HSE, FAA, FRA, MMS, NRC, DOT, DOE, CSB, NTSB, …) Safety Engineers, Coordinators, Professionals Reliability & Maintenance Engineers, Design Engineers, Facility Managers, Quality Auditors.
If you want to be the root cause analysis expert at your company, then this course is for you. This course is especially valuable for people interested in analyzing the causes of human error. You’ll earn rules and theories to help you improve human performance, including how to improve procedures, training, communications, human engineering, supervision, and management systems. You’ll also learn ways to improve your company’s investigation processes and procedures.
Senior Associate, Instructor
Six Sigma Black Belt
System Improvements, Inc.
1.865.539.2139 ext. 106
TapRooT® Changing The Way The World Solves Problems