Read a recent study that stated only 17.4% of ambulatory care nurses (surveyed) comply with all 9 precautions for infection control. Now first, for those who didn’t click above to see how the data was collected, I will let you know that this is SELF-REPORTED data (glean what you will from that tidbit of information). I would bet that compliance is actually much lower causing even greater concern.
To be fair, we are evaluating 9 different precautions. I will say that any statement that includes “wash hands” has low compliance … just walk into any men’s restroom to see that. But what would drives this? Let’s examine the items because it must be impossible to complete all of these, right? Here is the list:
- Provide care considering all patients as potentially contagious
- Wash hands after removing gloves
- Avoid placing foreign objects on my hands
- Wear gloves when exposure of my hands to bodily fluids is anticipated
- Avoid needle recapping
- Avoid disassembling a used needle from a syringe
- Use a face mask when anticipating exposure to air-transmitted pathogens
- Wash hands after providing care
- Discard used sharp materials into sharp containers
As a non-healthcare professional I don’t see a whole lot I disagree with. I mean, you are working with sick people, washing hands, wearing gloves, watch out for bodily fluids… can’t argue with that. So why do we have such low compliance? And remember this is “infection control,” so keeping healthcare professionals and other patients and staff safe.
Well, on our Root Cause Tree® we have a root cause under Management System->SPAC Not Used named, “No way to implement.” I bring this up simply to examine what we request in this list versus the very very dynamic environment in the hospital.
Can it be reasonable (except for the human self-preservation gene) to expect all of these to happen when working to save a coding patient? Or in a situation when an ER has very high census with multiple traumas (a situation I witnessed myself yesterday)?
I guess the answer truly is no. We are providing a SPAC that as written is reasonable, but can be difficult to implement during certain times. Thus, the very honest self-reported numbers.
Interestingly enough, I know the TapRooT®ers out there are all saying, “Hey dude, this is more of an Enforcement NI thing,” (you know you just did that, don’t act like you didn’t), but is it really Enforcement NI? I don’t believe in any way shape or form that you could enact an enforcement mechanism for all nine of these things, all at the same time, and give healthcare professionals the ability to perform timely patient care. The process would be so burdensome that it would crumble under the weight of its own scrutiny and patient care would suffer.
So is 17.4% compliance enough? Probably not, but let’s also remember what we are asking for people to do for that compliance. The number may not be acceptable, or palatable, but is what we can expect based on what is asked of these courageous folks working in this very difficult environment.
What do you think? Leave your comments below.
If this topic interests you, check out our medical track at the 2016 Global TapRooT® Summit. Breakout sessions include:
- 7 Deadly Sins of Human Performance
- TapRooT® Changes for the Medical Community
- Human Error Causes of Quality Problems
- Writing TapRooT® Driven Preventative & Corrective Actions Workshop
- Anatomy of a Medical Investigation & more!
GO HERE to download a .pdf brochure!
If it is written down, it must be followed. This means it must be correct… right?
Lack of compliance discussion triggers that I see often are:
- Defective products or services
- Audit findings
- Rework and scrap
So the next questions that I often ask when compliance is “apparent” are:
- Do these defects happen when standard, policies and administrative controls are in place and followed?
- What were the root causes for the audit findings?
- What were the root causes for the rework and scrap?
In a purely compliance driven company, I often here these answers:
- It was a complacency issue
- The employees were transferred…. Sometimes right out the door
- Employee was retrained and the other employees were reminded on why it is important to do the job as required.
So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.
Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.
What are some options to removing the blinders of pure compliance?
GOAL (Go Out And Look)
- Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
- Don’t just check off the audit checklist fro compliance’s sake, GOAL
- Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
- Learn how to evaluate your own process without the pure Compliance Glasses on.
If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.
Gary Passama, CEO of Northbay Healthcare, wrote an interesting article titled:
Click on the link above and see what you think.
It certainly would be nice to have accurate ratings so that patients could choose the best providers. What would it take to make it happen?
Communication has always been an issue within healthcare. From the earliest days of TJC alerts and the Event RCA guidance, communication has been a focus. There are multiple communication threads between practitioners, nurses, patients and family that create many avenues for possible problems.
As an example, I will use a story told to me by a friend regarding a recent surgical procedure. I will not try to recount the actual surgery as it is not truly relevant to this discussion. I will, however, start this story in Recovery after the person underwent surgery with no complications. During post-surgery recovery, they were provided with their formal discharge instructions from the nurse which included the following:
1) No lifting over 25 lbs for 1 week.
2) May return to work the next day.
3) Other medicine related and wound care information included.
After getting these instructions but before being discharged the surgeon came by to check on the patient and briefly discuss the procedure. During the discussion the following exchange occurred:
Patient asked the surgeon “Can I go back to work Monday?”
Surgeon asked, “What do you do?”
Patient answered, “Course setup and planning.”
Surgeon answered without hesitation, “You should be able to go back to work and perform that job without an issue”.
End of discussion.
See any potential problems with this communication? Any conflicting information? Very interesting isn’t it? Now, if we examine the duties within “Course setup and planning”:
1) Packing boxes
2) Shipping boxes
3) Lifting boxes
4) Computer work
5) Course Documentation
We can immediately determine that this job should be restricted based on the original instructions provided by the RN in the formal discharge instructions. But as with most people the words and advice from the surgeon were the ones that were heeded. My friend went to work on the next work day and continued to lift boxes that were in fact greater in weight than what was allowed. Now, in this case there was no additional injury, there were no complications, but this showed me in a glaring way how communications could cause a problem.
Now, had my friend had a complication and was forced to go back and receive an additional surgery, would this issue have been found as part of the RCA (if one were performed)? Did the communication have a role in the event? Here is a possible causal factor:
So during the examination of any event whether high or low risk, it is important to consider the impact of the spoken word. Looking into all communications that are involved to ensure that the messages sent match the messages heard. And that there are no conflicting communications that can cause confusion or set the patient or family up for failure. If you would like more information on how to consistently analyze healthcare related events using TapRooT® please feel free to contact me at: firstname.lastname@example.org.
Learn more about Healthcare RCA at the 2016 Global TapRooT® Summit.
Although technology has made medicine better and more consistent, this is probably something you never want to hear your doctor say.
This article raises a very fundamental question, are industries different when it comes to the causes of accidents? And even simpler, are job functions so different that they cannot have similar issues or problems?
Before we discuss this issue I want to start with a personal story. Many years ago I was giving a talk on Root Cause Analysis to a group of Physicians for a health system in Florida (about 50 if I remember correctly). The questions and discussion from the group had worked its way around to the difference in classes (jobs) within a hospital and the types of mistakes that are made. Understanding Human Performance as I do, I made what I thought was a simple statement of fact (and I quote),
Doctors and janitors make mistakes for the same reasons.
After the blank stares turned to surprise, contempt, then anger, I am sure you know the response I received. Later, once I escaped the room and was safely on a plane home, I thought about the reaction and came to the following conclusion. People truly believe that their job is different, different from any other, more important and difficult than any other. Is this perception? Or is this reality? Let’s find out …
Now, on the surface, I believe most people would say the answer to the question “Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?” will be a stern “No”. The widely-held belief is that the causes of these two issues have to be different. A surgical error made by a physician or nurse in a surgical suite has to be different from the errors made by a highly skilled tradesman causing an environmental release. They appear as different as night and day until you dig down deep into Human Performance and realize that both situations hinge on similar human factors. Let’s begin this search by looking at these two events along with causal factors for each:
Our Sentinel Event is: Surgery is performed on the wrong patient
Our Spill accident is: 500 gallons released environment
Here are a couple of causal factors, one for each. Looking at these two different situations do you see any similarities?
Both of these causal factors, although from different industries and different situations and job types, have similar causes to them. Both deal with Management System->SPAC Not Used->Enforcement NI. Both situations show a series of behaviors that have not been addressed or fixed by supervision or management, that have happened multiple times and have become common practice. Looking at our Root Cause Tree® Dictionary, we would get a yes to the following question in the Enforcement NI Definition for both:
- Has failure to follow SPAC in the past gone uncorrected or unpunished?
I think that shows that both of these situations have common systemic problems that have led to similar behaviors. There may also be other root causes based on other causal factors and other conditions presented here. But there is at least one common thread above.
One more example from the same incident, here are two additional causal factors:
Again, both of these deal with misidentification of a critical part of the system, one the patient receiving surgery and one a valve in a process. Now before I get emails saying that you can’t equate a human life to a valve, I understand that point and that is not what I am doing. I am simply showing that the quality of the “label” used to ID something (no matter what it is) can impact the end result. There are also other root causes here that may be different based on the data presented, but there are similar Human Factors that apply to both.
And just to make sure you understand the label in the industrial example used, here is the font and the label used:
So in the end, no matter what you do for a living, no matter how educated or experienced the person is, mistakes happen because of Human Performance based issues. The same issues affect us all no matter how different we believe our systems can be. This is exactly why our system is based on Human Performance and Equipment Performance principles and not based on industry variables and conditions. Our TapRooT® system has been proven to work in any industry equally as well. The only limitation that is put on the use of TapRooT® is the one we impose on ourselves based on our own professional bias.
If you would like to learn more about how TapRooT® can work in your industry please feel free to contact me at email@example.com or attend one of our public seminars. Our courses can be found at www.taproot.com/courses.
Read an article this past week discussing a hospital system investing $55 million to implement an EHR platform to improve efficiency within their hospital system (15 counties across all hospitals, offices and outpatient care facilities). They stated that the $55 million would be recouped by efficiency within 6 years of implementation. My first thought was, “Man that is smart”, being able to recoup almost $10 Million a year that is good business. Then the investigator in me thought, “Why don’t healthcare companies view RCA the same way?” Interesting question isn’t it? Is RCA, its Return on Investment (ROI) and its impact within healthcare undervalued?
Every healthcare professional understands the risks involved with patient treatment and patient care. These risks many times manifest themselves as Sentinel Events which are required to be analyzed through to Root Cause, and associated corrective actions. These are very visible issues that not only are known to the hospital but to the neighboring communities (at a minimum in today’s fast paced social network society). Doing some research I found some very interesting numbers provided by various sources that made me think, are we undervaluing the ROI from good root cause analysis of Events and issues in Healthcare.
From the Sentinel Event Alert #55 issued in Sep 2015 the following data on falls in healthcare is provided:
- Since 2009 there have been 465 reports of falls with injury (Sentinel Event Database)
- 63% of these reported falls (Sentinel Event Database) resulted in death
- The average cost of a fall with injury is approximately $14,000 (Industry research)
The alert above did not provide the cost of an actual fatality related event, but from general industry research that provided data over multiple industries (NIOSH) the average cost of a workplace fatality is approximately $944,000 dollars including all associated costs. I am not equating the two costs to be equal, but for this discussion I would believe this number to be commiserate with costs in healthcare for a Sentinel Event related fatality if you include damage to reputation, legal fees, compensation, and lost future business (to name a few).
So doing some basic math, over the time of this study the cost to healthcare organizations for reported patient falls would be:
- 63 * 465 = 293 fall related deaths
- 465 – 293 = 172 falls with injury
- 172 * $14000 = $2.41 Million
- 293 * $944000 = $276 Million
Total $278.41 Million
So reported falls with injury or fatality to TJC cost the healthcare industry approximately $279 Million dollars from 2009 to the present. The numbers when calculated across all Sentinel Event types are staggering. So by performing a very simple cost analysis, I believe it would be fair to say that stopping these types of events would be of value to any healthcare organization. So why are we failing? Why are we not investing more into these RCA systems and education to see greater returns?
Through years of talking and working with healthcare professionals I have heard the following:
- It is hard to put a cost on what has not happened
- Being both a Risk Manager, Patient Safety Manger and wearer of many hats I don’t have time to analyze everything
- We are only required to analyze Sentinel Events
- Healthcare is a very complicated process with many inherent hazards, things just happen
- We are performing well above average as compared to the healthcare industry
- We in healthcare can’t be compared to other industries… we are different
- RCA training and processes are too expensive when I get these tools for free
Although many of these statements are at their core true, the idea that “things just happen”, or that “we are different” in my mind are not reasons, they are excuses. A harsh answer I know but that is the reality I see. If failure is considered acceptable then I can certainly understand why money is not put into effective RCA and tools for better corrective actions.
But if I look at the cost of one fall with injury (not even a fatality), I believe that there is a very good justification for a better investment into your RCA. I will use the cost I am familiar with which is the cost of our public 5-day training. One seat at a TapRooT® 5-day Course (includes Software) is $2895. You invest that money, produce a high quality RCA including measureable and trackable corrective actions and prevent 1 fall with injury ($14000), you have an ROI of 3.84 on your investment immediately.
I know that your administration might not be impressed by saving $14,000, but an ROI of 3.84 is incredible! And extrapolate the $14,000 savings out across all the Sentinel Events, or the incidents that have a high potential risk, and the possible savings from a pure cost savings could be huge. And the return is not 5 to 6 years away… it is almost immediate. Reducing your rate of falls, or medication errors, or any other Sentinel Event type by even a small percentage can show an IMMEDIATE return on that investment. Having multiple people trained and experienced in your RCA program simply becomes a multiplier towards that ROI and the improvements to Patient Safety and lowering risk.
The old saying, “Getting out what you put in” is very true when it comes to your RCA program. Don’t undervalue the impact of what a bad RCA is costing you and prove what good RCA tools can save your organization immediately. If you provide your employees with the best tools, the right level of training and knowledge, and put those tools to work, there will be a return on that investment for both your organization and for your clients/patients. If you have any questions about improving your RCA program please contact me at firstname.lastname@example.org or call me at 865-539-2139.
I have been teaching RCA now for almost 20 years and have found that Generic Cause is many times the simplest yet most confusing step in our RCA process. The first 4 steps from Getting Started (reporting) through Root Cause Analysis (Root Cause Tree®) move very efficiently. But transitioning from “Specific” root causes linked to Causal Factors to “Generic” causes that tie multiple events together seems to trip up many professionals.
What is a Generic Cause?
First let me start with a quick discussion of our philosophy on Generic Cause. Step 5 in the process flow above addresses this issue prior to developing your Corrective Actions. We need to first understand the “Specific” root causes from Step 4, and the “Generic” causes before we begin developing Corrective Actions so both can be addressed.
The definition of a “Generic” cause in our system is as follows:
The Systemic problem that allows a root cause to exist, across multiple incidents or sites or systems.
This is a bigger picture issue that is allowing the same root causes to exist across multiple events. So that being said, let’s dig into the article above to provide a description of a “Generic” issue.
The Duodenoscope Example
The article discusses a particular type of duodenoscope produced by one manufacturer used across the healthcare industry. This particular scope had been linked to multiple cases where infection had been spread to patients. So similar infections, when investigated by individual hospitals, provided data showing that this particular type of scope was involved. Breaking down that statement, we have the following:
- Same brand and model duodenoscope
- Used in multiple facilities over a term of 5 years
- Multiple instances of infection transmission following use of this scope
Are you seeing the pattern in this list? Something is similar in all these instances… the scope itself. Now, from the article (which does not provide any RCA data), I can only speculate on the Root Causes for this “spread of infection” as it relates to the scope… from the Corrective Actions taken by the manufacturer it looks as if there could be any of the following issues:
. . . A. Equipment Difficulty->Design->Specs NI
. . . B. Equipment Difficulty->Preventative/Predictive Maintenance-> PM NI-> PM for Equip NI
. . . . . .1. If you assume the cleaning procedures and recommendations to be Preventative Maintenance
…………..on the scope
. . . C. Human Performance->Procedures->Wrong->Facts Wrong
. . . . . .1. If here you assume the cleaning instructions are procedures and they did adequately provide
…………..information on cleaning the scope.
Any of these could relate back to the Corrective Actions which include the recall, a redesign of the scope as well as changes to the cleaning requirements.
Finding Generic Causes in Your Organization
Now looking at these causes, and the list of items that meet the definition of a Generic cause, I have to ask everyone reading this article:
How would you as an organization know that you are having Generic problems?
The answer to that question will probably vary from organization to organization but there is probably one key element. That key element is consistent Classification of events, consistent Root Cause Analysis, linking your Causal Factors (on the Causal Factor Editor) to specific Equipment types and Departments, and effective trending and data analysis. Without a clear, well defined classification schema for all investigations or incidents within a healthcare facility/system it would be nearly impossible to trend your RCA data and determine where similar causes and events are happening.
Once you get a standard Classification list together, and consistently classify your events, you can now perform a couple of different Trending functions (from the TapRooT® Software v5.3) to determine Generic Causes:
- Search your data using our Root Cause Distribution Report by filtering Classification and over a date range to see all causes produced. If you find a particular root cause across those RCA’s you may have a generic cause.
- Run a Pareto Chart using Equipment as your X-axis and Counts as your Y-axis on the chart to look at counts. See if one piece of equipment is linked to 70-80% of your causes… this might give you a clue to a Generic Issue
- Run a Process Behavior Chart looking at a Specific Classification, and run an “Instant Rate” chart or an “Interval Chart”. These would cue you in on if your rate of failure is increasing or if your time between occurrences is decreasing respectively and may provide some insight into your overall Equipment or program health.
If you have any questions about Generic Cause or any additional Trending functions please feel free to contact me at email@example.com
For many years, the culture within healthcare has been focused on reducing medical errors, minimizing impact on the patient through sentinel event analyses, performing proactive analyses on high risk processes using FMEA and raising awareness about risk reduction and patient safety.
All of these efforts have huge merit and a very high visibility within and outside of the healthcare community. When we enter a hospital we (as clients and patients) have the expectation to leave in better shape than we arrive. We certainly do not expect harm to come to ourselves or our loved ones but when things can and do happen the expectation is that the organizations will learn and improve. Thus resources and money are applied to the RCA programs around these visible events.
So with all these programs and efforts put towards the “clients” within healthcare I have always wondered, “Are there resources or efforts left for workplace safety within healthcare?”.
The article on “10 top safety issues for 2016” by Becker’s Infection Control and Clinical Quality Newsletter brought this thought back to me by listing the following 2 items as risks towards Patient Safety:
1) Workplace Safety, focused on the safety of healthcare workers
2) Hospital Facility Safety, focused on building or maintenance type issues
When I read the entire list it was so in line with our philosophy on the impact of systems and the workplace on healthcare professionals themselves. When we think of performing root cause analysis we think of problem solving, fixing what was wrong by implementing corrective/preventative measures and thereby creating a safer environment. If we create a safer environment for those who work in a healthcare setting, our caregivers, wouldn’t we also be creating a safer environment for patients and visitors within the same framework? I believe so.
One of the first principles we teach in all of our TapRooT® training programs involves defining the “incident” or in healthcare terms the “Event.” This becomes the circle on our SnapCharT® and by its nature is the focus of the investigation and the issue or occurrence we want to prevent in the future. The incident can be ANY problem you wish to solve, ANY adverse event or occurrence needing evaluation… it does not have to solely sit at the top of the Patient Safety or Risk hierarchy.
Let’s take a quick quiz, here is the question:
Which of these issues could be investigated using the TapRooT® Methodology?
A) Medication error resulting in long-term harm to a patient
B) Nurse strains their back trying to reposition a patient causing lost time
C) Patient spouse slips on a loose tile in the main hallway outside the Pharmacy
D) Hospital administrator slips on water leaking from the fire system in admin wing
E) Backup generator does not start in time to provide uninterrupted power
F) All of the above
Well what do you think?
If you answered “F – All of the above” you are correct! All of these problems or issues can cause adverse impact to your organization. All of these problems can cause a cascading effect on both patient care as well as employee safety.
The TapRooT® process has tools and a language that fits all these situations without having to change your RCA approach or methodology. The same thought process applies to both the clinical and non-clinical issues facing your organization. The 7-step Process Flow used in the Sentinel Event training course is the same that we use in our Equifactor® (Equipment Troubleshooting) training course, as well as our public RCA seminars. Human Performance and Equipment performance are the same from the investigative perspective no matter what the problem you are trying to solve.
So as we enter 2016, I want you think about others inside your organizations outside of the clinical organizations that can benefit from the same tools Patient Safety and Risk Management use in TapRooT®. Maximize your use of the process to maximize your return on investment in training… your facility maintenance personnel, your facility administration personnel… anyone who is tasked with problem solving and troubleshooting can benefit as well. Create a safe work environment for those closest to you (your employees), and you also create a safer environment for your clients (patients and our loved ones).
If you would like information on our training courses for Root Cause Analysis, Equipment Troubleshooting, Evidence Collection or any other TapRooT® courses please contact me at firstname.lastname@example.org or call me at (865) 539-2139. I would love to help you create the total environment for patient care.
Found this cartoon and truly laughed out loud (or as the Millennials put it, “LOL” or “Hahaha”). Working with healthcare has truly shown me the complexity of the business including making very educated judgments in a very complicated environment (physical and physiological). I thought this might just provide our healthcare TapRooT® users a respite from an otherwise serious job… and maybe a few interviewing questions to boot when performing the next RCA… such as “did the patient have 100+% limbs?”
What do you think? Leave your comments below.
While reading Sentinel Event Alert 55 (SEA-55) from TJC issued September 28, 2015 on Fall Prevention, it occurred to me that TapRooT® can be used to aid in finding the root causes of the fall. Even more importantly, TapRooT® can be used to aid in maintaining your fall prevention program to ensure long-term success. The TJC lists the following common contributing factors (in TapRooT® these would be called “Causal Factors“):
- Inadequate assessments
- Communication Failures
- Lack of adherence to protocols and safety practices
- Inadequate staff orientation, supervision, staffing levels and skill mix
- Deficiencies in the physical environment
- Lack of Leadership
While these are good guidelines for what to look for and what data to gather, to us these do not represent root causes. These 6 items almost match up with most of the 7 Basic Categories on the back of our Root Cause Tree®. So as TapRooT® investigators, know you have to dig a bit deeper to find the true causes and define those at the Root Cause level not at the causal or contributing level.
All this being said, the more important reason I wanted to write this article is to highlight the use of your TapRooT® tools by using them for Proactive measures. How to examine and improve your fall management program and maintain continued success. Too many times we don’t think about the power of observation and the idea of raising awareness through communication. Each of these can be highlighted through the Proactive Process Flow below:
In SEA-55, two of the actions suggested by TJC were to 1) Lead an effort to raise awareness of the need to prevent falls resulting in injury and 2) Use a standardized, validated tool to identify risk factors for falls. These two items can benefit from the TapRooT® tools directly.
Starting with step 1 above in the Proactive Flow, use the SnapCharT® tool to outline the steps in patient assessment, highlight the steps that can or will affect the fall prevention portion of patient care, then use this flow as the basis for an observation program. By getting out and observing actual performance in the field you can do two things, show your concern for patient safety (and falls in this case) and gather actual performance data. These observations can be performed both in a scheduled and/or random fashion and can be done in any setting (ambulatory, non-ambulatory, clinic et cetera).
During the observation, document findings on the SnapCharT® and identify potential “Significant Issues” as they apply to fall prevention. This data can then be either evaluated using the Root Cause Tree® to define the areas of need for that single observation, or the data can be combined with other fall prevention observation data for use in an aggregate analysis or common cause analysis. With the aggregate analysis data from multiple observations can be combined, and “Significant Issues” can be identified based on multiple observations before an analysis using the Root Cause Tree® is performed. This could give you an overall bigger picture view of your processes.
Once the RCA is performed (in either situation), Steps 5-7 can be simply followed to produce some recommended actions to be implemented and measured using Corrective Action Helper® and SMARTER. And the beauty of this Proactive process is that you have not waited for a fall to learn. You and your organization are preventing future issues before they manifest thus showing your patients and staff that you truly care about their safety.
If you would like to learn more about using your TapRooT® tools proactively you can contact me at Skompski@taproot.com for more information or you can attend any of our public seminars, 2-day or 5-day to learn more on both the reactive and proactive use of the TapRooT® tools!
- Training. Retrain everyone, not just those involved.
- Policies/Procedures. Write new policies or procedures or make the current ones longer.
- Discipline. Send a message to everyone else that a behavior is unacceptable whether or not there is fault.
When these are the standard actions, many times we have recurrence of events. I am not saying these actions can’t work, but many times if they are default answers it is much like putting a round peg in a square hole.
In this article a hospital in Hong Kong presents an overview of their findings and recommended actions to a Sentinel Event at the hospital. Review the Corrective Actions and ask these two questions:
1. Do they meet the needs of the system based on the findings?
2. Do you see a correlation with our three standard corrective actions above?
Maybe there is a pattern… let us know your thoughts.
For many years now the TJC and other governing bodies have required root cause analysis (RCA) on Sentinel events as well as analyses on near misses with high potential. To remain accredited, organizations have put together teams to perform analyses to find the causes and to recommend, implement and track corrective actions. Throughout this time of focus and effort there continue to be repeat sentinel events. So the question that arises is, why are these RCA’s failing?
This question may appear very complex but the root of the problem is actually very simple. From reading many Event reports and examining how many organizations perform these analyses two things stand out to me:
- Many analyses stop at too high a level due to a lack of information and do not reach true root causes. They stop at what we define as a Causal of Contributing factor.
- Many corrective actions don’t address the root cause due to the limited analysis or because the corrective actions created are not specific to changing a particular behavior or system.
What truly makes this even simpler is the fact that these two issues are interrelated. If you don’t thoroughly gather the correct information and identify the true root causes the corrective actions may not be focused enough to fix the problem. We will then fall into the trap of implement general or employee focused corrective actions that don’t address system problems. This can result in wasted time and resources and can have a very negative impact on the people involved in the event.
Here you see an example where the investigator stopped gathering data at a Causal or Contributing Factor.
In this example there was a mistake made by the nurse when retrieving a medication for a particular patient. With no additional information gathered, the investigator is forced to stop at this level. No more analysis can be performed without many assumptions and opinions being used. In this case, when the team moves to corrective actions, how do you fix someone retrieving the wrong medication? Well, without any additional information, we counsel the employee to be more careful, we punish the nurse for making the wrong choice, and/or we retrain everyone to make sure there is an overall understanding of this issue. None of these truly change the system and address the causes of the issue (as you will see below).
If the investigator gathers much more information on the issue there is at least a chance to more thoroughly examine the issue using your RCA tools and dig deeper to a root cause level.
Having this additional data available allows the investigator to dig deeper into the issue to identify the underlying system root causes that contribute to this mistake by the nurse. This changes the focus to the organizational systems and not solely on the individual. Knowing that it has become common practice during high census to not follow the second check rule (or 5 Rights) and there have been no negative consequences consistently provided by management for this issue we would be able to identify system related causes such as Management System ->SPAC Not Used ->Enforcement NI (from the Root Cause Tree®) and other causes. By getting to this level of analysis and understanding the system cause(s), we can now build corrective actions to address specific system issues. By addressing the specific causes and in this case changing the rules or terms around times with a higher than normal census, the requirements for following and consequences for not following this policy we are changing the systems in the organization. By changing the systems we can enact long lasting positive change in the organization and build sustained success and change the behaviors of our employees.
A man was seen fleeing down the hall of the hospital just before his operation.
“What’s the matter?” he was asked.
He said, “I heard the nurse say, ‘It’s a very simple operation, don’t worry, I’m sure it will be all right.”
“She was just trying to comfort you, what’s so frightening about that?”
“She wasn’t talking to me. She was talking to the doctor.“
Henry the Hand brings you the “T Zone Teaching Moment.”
Here is the video …
Visit this web site for more information:
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
Do you have incidents that happen over and over again?
Do you have repeat equipment failures?
Does your hospital have similar sentinel events that aren’t solved by your root cause analysis?
How much are these repetitive problems costing your company?
Stop making excuses and try something NEW that can help you stop repetitive problems…
IDEA #1: Attend at TapRooT® Course to stop repeat incidents.
Choose from the:
- 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
- 3-Day Equifactor®/TapRooT® Equipment Troubleshooting & Root Cause Analysis
- 2-Day TapRooT® Healthcare Root Cause Analysis Course
- 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course
These courses are guarantee to help you find root causes that you previously would have overlooked and develop corrective actions that both you and your management agree are more effective.
IDEA #2: Attend the Creative Corrective Actions Course.
Hurry, this course is only offered on June 1-2, prior to the TapRooT® Summit. If your creativity for solving problems is getting stale, this is the course you need to attend.
IDEA #3:: Attend the 2015 Global TapRooT® Summit in Las Vegas on June 3-5.
The Summit is a proven place to network and learn valuable best practices that can help you solve your toughest problems. Each Summit is unique, so you don’t want to miss one. And this year’s Summit is rapidly approaching. Register today at:
Michele Lindsay, President of Performance Potential Inc. and member of the Quality and Risk Department at Southlake Hospital recently shared this awesome video with us. Join Michele at the Global TapRooT® Summit June 1 and 2 for her exclusive 2-Day Creative Corrective Actions Course and sign up for the Improving Healthcare and Patient Quality track June 3 – 5 to attend her best practice session, RCA of Multiple Events, which is a case study of performing root cause analysis on several incidents that appear to be related. Take the opportunity to learn from many incidents that may not trigger a root cause analysis on their own, but collectively provide significant insights into process and system weaknesses so effective corrective actions can be put in place.
Hope you enjoy the video! Learn more about the 2015 Global TapRooT® Summit at:
Come learn the TapRooT® process with other healthcare professionals and understand why the TJC recognizes our terminology and understands the quality of what TapRooT® provides in healthcare. Ed Skompski will lead this 2-day course offered June 1 and 2, 2015 in Las Vegas, Nevada — right before the 3-day Global TapRooT® Summit.
Ed Skompski,Vice President
This course provides the basic building blocks of performing both a reactive TapRooT® investigation as well as the use of the TapRooT® tools for Proactive analyses.
With clinical examples and healthcare experts teaching, this learning experience will provide you with the best RCA tools on the market and the knowledge to use them. Tools include:
- SnapCharT® for organizing and understanding the data you collect;
- Root Cause Tree® and Dictionary for finding consistent, real root causes that you can communicate to your organization; and
- Corrective Action Helper® and SMARTER tools to help you define detailed, measurable corrective actions to prevent future events.
All of this adds up to a great training session that you will find to be not only valuable but also practical and useable.
REGISTER for this course and the Improving Healthcare Quality & Patient Safety track at the Summit:
REGISTER for this course alone: http://www.taproot.com/store/2-Day-RCA-Sentinel-Events-1506LASV01.html
LEARN MORE about the 2015 Global TapRooT® Summit: http://www.taproot.com/taproot-summit
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?
This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.
Click here for more information regarding our TapRooT® courses around the world.
And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.
Was this tip helpful? Check out more short videos in our series:
Prevent Equipment Failures with Ken Reed (Click here to view tip.)
Be Proactive with Dave Janney (Click here to view tip.)
Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)
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.)
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:
Watch this video and see how TapRooT® could have been used for root cause analysis…
I just can’t get by the number. Over 400,000 people die each year in US hospitals due to medical errors. That’s over 1,000 per day. Or one or two in the time it takes you to read this article.
This latest estimate came from a study published by Dr. John T. James Ph.D. His estimates are the best numbers we have. Why? Because these deaths aren’t tracked like auto accidents or industrial safety accidents. medical errors are historically under-reported if they are reported at all. That makes it hard to tell if a particular hospital is doing poorly or if we are making improvements across the healthcare system.
As everyone who has read quality guru W. Edwards Deming’s book Out of the Crisis knows, you must have accurate data to guide improvement. Without it, you are shooting in the dark.
What can we do to improve patient safety? It depends on where you are in the system.
Patients can become informed (hard to do) and insist on the best treatment. For some ideas, see:
Those in the healthcare system should be striving to improve performance. How? Use TapRooT® to investigate medical errors and develop effective fixes is a start. But you can do more including learning new performance improvement ideas at the TapRooT® Summit.
I’d like to think there was a regulatory or government effort that could work miracles, but I’m afraid that most of the legislation in the healthcare arena has been a failure (and calling it a failure is probably generous).
So as a patient, arm yourself. And if you are a healthcare professional, do what you can with what you have to make progress possible.
What if you are in the government? Would it be too much to ask for accurate, public reporting of these accidents?