Taproot

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.

The benefits:

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.

Mumbai, India Feb 21 – Feb 25 Register

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 info@taproot.com or chris@taproot.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.

Best Regards,

Chris Vallee
Senior Associate, Instructor
Six Sigma Black Belt
Human Factors

System Improvements, Inc.
1.865.539.2139 ext. 106

http://www.linkedin.com/in/christophervallee

TapRooT® Changing The Way The World Solves Problems

The US isn’t the only place where medical mistakes are made. Here are links to several medical accidents (sentinel events) …

Video of Nurse Error

Mother Died of Mix Up

Surgeon Cuts Off Testicle “By Mistake”

The story posted on CNN.com says:

“Unthinkable errors by doctors and surgeons — such as amputating the wrong leg or removing organs from the wrong patient — occur more frequently than previously believed, a new study suggests.”

“Over a period of 6.5 years, doctors in Colorado alone operated on the wrong patient at least 25 times and on the wrong part of the body in another 107 patients, according to the study, which appears in the Archives of Surgery.”

For the whole story see:

http://www.cnn.com/2010/HEALTH/10/18/health.surgery.mixups.common/index.html?hpt=T2

Tell me it ain’t so…

I heard yesterday the Oregon Patient Safety Commission is teaching hospitals in Oregon to use 5 Whys to find root causes. Let’s just hope “it ain’t so.”

If you don’t know why I think 5 Why’s is a bad practice, read these:

http://www.taproot.com/content/archives/710

http://www.taproot.com/content/archives/1001

http://www.taproot.com/content/archives/12405

http://www.taproot.com/content/archives/134

http://www.taproot.com/content/archives/9204

http://www.taproot.com/content/archives/2801

http://www.taproot.com/content/archives/569

http://www.taproot.com/content/archives/4577

And that’s not all.

Want to learn truly effective root cause analysis? Something so good, industry leaders around the world are using it? Root cause analysis with patented software? Then see this list of courses:

http://www.taproot.com/courses.php

I continue to see sentinel event after sentinel event reported in the press. These are usually local articles. A single patient death doesn’t hit the national news.

However, healthcare reform has been in the headlines all year long. What is it going to be? Will it pass? What is in it? Will it be repealed? Story after story…

That got me thinking … Has healthcare reform caused patient safety to take the back seat?

First, in a cost cutting environment, new initiative (like patient safety) usually get cut. After all, how can we spend money on a new program when we don’t have enough money for current programs.

Second, new equipment for new type of surgery that produces revenue and puts one hospital ahead of another seems much more likely to get funding that patient safety (which, I’ve heard people say, is just people being careful).

Third, no government mandate has made patient safety an overriding priority. After all, if patient safety was more important than healthcare reform, wouldnt they have passed a patient safety law first?

Finally, hospitals and healthcare providers have become accustom to the current patient safety environment and have provided for the risk of malpractice suits by obtaining insurance. But you can’t buy insurance for changes in healthcare reimbursement rates due to new laws. So medical administrators tend to pay more attention to the risk they can’t control rather than the one that they have become accustom to and have insured against.

This shift in focus is a sad state of affairs.

If you look at the money being spent on insurance (insuring doing things wrong) and the amount of money spent treating people for sentinel events, hospital acquired infections, and misadministration of drugs, the sum is truly amazing. An article from last summer put the cost of the aditional treatment due to medical mistakes at $17 billion per year. And that’s just the cost in the US. Accident rates and costs are similar around the world (there is no error free healthcare system).

So what needs to be done?

First, each healthcare facility has the moral obligation to improve patient safety. They should be looking for every opportunity to implement advanced improvement techniques. These can be learned from other healthcare providers but, more often than not, come from outside the healthcare industry.

Where should they be looking outside the healthcare industry? The nuclear industry, commercial aviation, oil and petrochemical, the military, mining, and  high tech manufacturing are just a few of the possibilities. These industries have had to find ways to improve human and equipment reliability or they would go out of business (either because of cost or regulatory action).

But where could a healthcare provider meet with leaders from these industries from around the world? The only place I know of is the TapRooT® Summit in San Antonio, TX. But that is only three weeks away. You will have to hurry if you believe that patient safety is really a top priority and your facility needs to do as much as possible.

For the complete TapRooT® Summit schedule, including the Healthcare Quality, Patient Safety, Sentinel Event Track, see:

http://www.taproot.com/summit.php?t=schedule

Click on the buttons on the right to see the topics in each track. When you sign up for the Summit you can customize your sessions to make your experience target the biggest problems at your facility.

Here’s the video of the press conference:

The Seattle PI reported that the hospital is having a day long safety stand down and is having and independent root cause analysis performed.

My question is why past root cause analyses haven’t prevented these accidents. Also, why didn’t proactive audits, assessments, and observations prevent these accidents?

This is hard to judge from a distance. Are the root cause analyses being performed effective? We could say they the root cause analysis and corrective actions were effective if the problems stopped. It would be interesting to see a SnapCharT® of the incidents, a Safeguard Analysis including what Safeguards failed and which Safeguards worked. Then I would like to see each of the Causal Factors and how they would be taken through the Root Cause Tree®. Finally, I would compare their corrective actions to those in the Corrective Action helper® Module.

Without a thorough analysis, determining if this hospital is really solving the system problems is impossible.

The Seattle PI article says:

“One of the reasons mistakes continue to plague health care is that many facilities are not reporting their mistakes, despite state laws requiring that they do so. Experts say error reporting and analysis leads to improved care over time and ultimately saves lives.”

For the rest, see:

http://www.seattlepi.com/local/427266_medicalerrors23.html

Can an equipment issue and an operations problem cause a quality issue that causes a sentinel event?

YES

It did in Ireland seven years ago. And the results of the investigation have just come to light.

The Irish Times published the following accident scenario.

1. A computer on a production line at at B Baun Medical froze (an equipment issue) and caused the line to stop.

2. The bag of adult food from the line was discarded.

3. The normal practice of flushing out the pipe that fed the line wasn’t accomplished because of “human error” and shift “changeover”.

4. The next batch to be produced was premature baby food. The Adult food that contained 126 times the allowed dose of magnesium (which was still in the pipe feeding the line) was put in the baby food packages.

5. This food was fed to a premature infant and the result was permanent, irreversible brain damage that resulted in the baby’s death five years later.

The Irish Medical Board investigated the problem within two weeks of the  incident in May of 2003. But they didn’t release the results to the family.

Finally, seven years later, the family found out what happened as a result of a coroner’s inquest which ruled the death a “medical accident”.

That reminded me of one of the Keynote Speakers at this year’s Summit on October 27-29 in San Antonio.

Linda Kenney had a sentinel event happen to her. The long difficult process led her to create the Medically Induced Trauma Support Services organization. It helps patients, their families, and doctors communicate better and heal emotionally after a sentinel event.

To hear Linda’s story and learn more about dealing with the aftermath of an accident, attend her Keynote talk at the TapRooT® Summit.

Do you need to improve patient safety? See the 2010 Summit info at:

http://www.taproot.com/summit.php

Don’t wait to register. The Summit is coming up on October 27-29.

In June, the Society of Actuaries published  a study that estimates the cost of medical errors in the United States. titled: The Economic Measurement of Medical Errors.

What was the cost for errors in the US per year?

$19.5 billion dollars

Most of this cost ($17 billion) was for direct costs associated with increased patient care due to the error.

In other words, medical facilities had a $17 billion increase in revenue because they made mistakes.

Until recently, insurance and medicare/medicaid paid for correcting errors. Thus the only financial incentive to reduce errors was to reduce malpractice claims.

Because malpractice claims were not soon and certain, the incentive to improve systematically just didn’t exist.

This may be changing because Medicare/Medicaid and some insurers are starting to eliminate payment for at least some types of errors. Thus, medical facilities will have a financial incentive to prevent these errors.

We’ll watch to see how this improvement goes based on economic incentives.

By the way … these costs don’t include medication errors.

If you are at a medical facility and would like to learn more about improving performance and stopping sentinel events, consider attending the TapRooT® Summit in San Antonio, TX, on October 27-29, 2010.

Here’s a link to the Summit schedule:

http://www.taproot.com/summit.php?t=schedule

Click on the “Healthcare Quality, Patient Safety, Sentinel Event” button to the left of the schedule to see the sessions in that track.

This 5-Day Root Cause Course was definitely an adventure. When you start with a class of combined industries such as Mining, Military Health, Manufacturing, Nuclear, Power Generation, Drilling, Oil, Gas, and Chemical, day one starts off like this…..

“Our Industry is different than ________ (fill in the blank).”

Can you point out who is from what Industry? At the end of the 5-day, all industries were having the same conversations and sharing best practices…. I love TapRooT® Public Courses!

An evening with the Military Health Group above…. great discussions with members’ assignments spreading from Texas all the way to Korea.

Some more pictures from the course below.

Read more here: http://news.yahoo.com/s/ap/20100728/ap_on_he_me/us_med_hands_only_cpr

A Canadian Health Unit report said that a doctor’s cataracts are partly to blame for incorrect pathology reports that led to an unnecessary colostomy, two mastectomies, and at least four other cases of “serious concern.”

The story was reported by healthzone.ca. See the whole story at:

http://www.healthzone.ca/health/newsfeatures/article/840505–doctor-s-cataracts-partly-blamed-for-medical-error

How would you detect the gradual decline of someone’s visual acuity/performance that what a key part of their job?

With corrective surgery for cataracts so common and available, why didn’t the doctor act before his performance declined noticeably?

Should hospitals have a requirement for periodic eye test for older physicians whose practice required visual acuity?

..”About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.”

..”Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.”

..”The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.”

…”Malfunction and misuse are among possible reasons”

I read the article and then asked “AND”? There is so much more information that needs to be collected and compared.

… “is there damage with this equipment for children and adults?”

… “is there a difference between different manufacturers for the same types of equipment?”

…”what allowed 70,000 incidents to occur without having the root causes listed already?” …. yes I know there are patient and company privacy issues but that is not a good excuse!

So what would your next steps be? (more…)

While this was my third tour to Saudi Arabia, this was my first true Saudi Culture experience while in Riyadh. My first two trips were with the United States Air Force for two tours of duty. These pictures are posted with great appreciation to the employees (my friends) from the Saudi Food and Drug Authority.

Until recently, skyscrapers were not allowed to be built (a night time picture from the skybridge)…..

Experiencing Authentic Arabic Cuisine

History of and formation of a Unified Saudi Arabia

The first Medical Devices in Saudi Arabia

The newly developed SFDA (Saudi Food and Drug Authority) located in Riyadh, Saudi Arabia, has taken the lead in medical oversight of conformity; not only by creating a Medical Devices Sector, but also by ensuring that their Medical Device team has a thorough understanding of human error and equipment failure and has the best tool to investigate it with, TapRooT® Root Cause Analysis.

Here are few pictures taken during the onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis, 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis, Stopping Human Error, and 1-Day Evidence Gathering Courses held in June.

If you look closely you can see that they are using the new individual software… (another user test to make sure it is ready to go out to all users)

A TapRooT® User passed along an article about doctor fatigue. His comment? The medical industry really needs TapRooT®.

Here’s the article:
http://www.usatoday.com/news/opinion/forum/2010-06-02-column02_ST1_N.htm

The article tries to justify fatigued doctors by showing some problems that reduced work hours might create.
Instead of applying techniques to fix these new problems, they imply that fatigued (error prone) doctors may be the only answer.
For example, they quoted an article written by two Vanderbelt surgeons that claimed that more than 80 hour work weeks were required to allow surgical trainees to learn techniques, dexterity, and stamina required in their profession.
Perhaps the surgeons should have been looking for more effective ways for students to learn and develop the skills they need since long hours is not the only way to learn (and adequate sleep is needed to embed even muscle memory – like that needed for basketball or surgery.
I’ve worked 80 hour weeks under high stress. I’ve done 24, 36, and even 72 hour workdays. I can tell you that you don’t want a doctor near the end of a 36 hour shift (or even at 4 AM if they came in to work the previous day at lunch.
Don’t buy the argument that fatigued doctors are just a fact of life. Every problem mentioned has solutions. Fatigued doctors ARE NOT the solution. They are one of the problems that keep people from getting quality care.

Sometime people have an accident happen to them and nothing is learned. On the other hand, an accident can provide an opportunity to see problems in a different light.

Linda Kenney was the “victim” of a sentinel event. But the learning she has led after the sentinel event isn’t about how to prevent mistakes. Rather, she helped people see that doctors and patients, and their loved ones need support after these types of accidents.

Read about her story at:

http://www.psqh.com/janfeb05/consumers.html

Then come to the TapRooT® Summit to hear her story first hand and to learn from other great Keynote and Breakout Session Speakers.

Part of the Summit is helping investigators understand the human side of accidents. Linda Kenney will speak at the Summit about her traumatic incident. See these videos to learn about her story…

PART 1:

PART 2:

Attend the TapRooT® Summit (October 27-29 in San Antonio, TX) and hear her story first hand as well as other great General Session and Best Practice Session Speakers.

What do you do after an accident for those that are impacted by the accident? Linda will talk at the TapRooT® Summit about her medical sentinel event and how people involved need to be supported.

Here’s a video that will provide you some background about Linda and MITSS.

Dear Friends –

While influenza outbreaks appear to be slowing, neither the WHO, nor CDC has declared an end to this pandemic. There are still some areas with widespread influenza activity.

NOVEL H1N1

In an overview of flu activity during the 2009-10 flu season that started Aug 30, the US Centers for Disease Control and Prevention (CDC) said pediatric deaths from the pandemic virus are three times higher than the average for the past three seasons. Flu activity peaked on Oct 24, much earlier than the February peaks of the most recent flu seasons. The CDC pointed out that multiple waves were seen during the three most recent pandemics, emphasizing the importance of vaccination. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5902a3.htm?s_cid=mm5902a3_x

Though older people appear to have some immunity to the pandemic virus, the US Centers for Disease Control and Prevention learned of several outbreaks at nursing homes, detailing three in Morbidity and Mortality Weekly Report (MMWR). They occurred during the fall before the vaccine was widely available, and infections in healthcare workers were documented at two of the facilities. Infection control steps and antiviral prophylaxis seemed to slow flu spread. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a3.htm?s_cid=mm5903a3_x

            A new study is shedding light on the immune response of the elderly to H1N1. This study demonstrates that in Finland, individuals born between 1909 and 1924 and to a lesser extent those born between 1925 and 1944 have pre-existing humeral immunity against the 2009 pandemic H1N1 influenza A virus.

·   Ninety-six per cent of individuals born between 1909 and 1919 had antibodies against the 2009 pandemic influenza virus.

· Those born between 1920 and 1944, the prevalence varied from 77% to 14%.

· Most individuals born after 1944 lacked antibodies to the pandemic virus.

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19478

H5N1

During 2009, 73 laboratory-confirmed cases of human infection with highly pathogenic avian influenza A (H5N1) virus were reported to WHO from 5 countries. The 73 laboratory-confirmed cases of H5N1 virus infection were reported from Cambodia (1 case), China (7), Egypt (39), Indonesia (21) and Viet Nam (5); all of these countries reported human cases of H5N1 previously. Circulation of highly pathogenic H5N1 virus in poultry is considered to be endemic in these countries.

With almost double the number of human cases of H5N1 reported in 2009 compared with 2008, and with continuing circulation of the virus among certain poultry populations, it is clear that H5N1 remains a concern for both animal health and public health. http://www.who.int/wer/2010/wer8507.pdf

VACCINE

            Given signs that the pandemic H1N1 virus will continue its dominance over other flu strains, the World Health Organization (WHO), CDC, FDA, etc. have recommended adding the pandemic strain as the H1N1 component of the seasonal flu vaccine for the Northern Hemisphere’s next flu season. Additionally, they have also changed the other influenza A strain, replacing the Brisbane H3N2 component with a Perth H3N2 strain. The influenza B component (changed last year) remains the same.The recommendation for next season’s vaccine:

·   A/California/7/2009 (H1N1)-like virus

· A/Perth/16/2009 (H3N2)-like virus

· B/Brisbane/60/2008-like virus.

The Advisory Committee on Immunization Practices (ACIP) voted to expand the recommendation for annual influenza vaccination to include all people aged 6 months and older. The expanded recommendation is to take effect in the 2010 – 2011 influenza season. The new recommendation seeks to remove barriers to influenza immunization and signals the importance of preventing influenza across the entire population. The vote took place against a backdrop of incremental increases in the numbers and groups of people recommended for influenza vaccination in years past, and lessons learned from the world’s still ongoing first flu pandemic in 40 years.

http://www.cdc.gov/vaccines/recs/acip/

OTHER

            In an effort to maintain the nation’s supply of drugs and other medical products in the event of a pandemic or other emergency, the US Food and Drug Administration (FDA) recently issued guidance to help pharmaceutical companies plan for high absenteeism rates. It focuses on “medically necessary products” such as antivirals and details what the FDA could do to help protect the supply. The guidance is also aimed at companies that make the raw materials and components used in the products. http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM196497.pdf

College students living in dorms reduced their risk of influenza-like illness (ILI) at the peak of the flu season by wearing surgical masks a few hours a day and practicing good hand hygiene, say researchers from the University of Michigan. There have been many studies that point out the effectiveness of masks, hand hygiene & social distancing as very effective tools. http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/jan2210masks.html

COMMENTARY

                        As the H1N1 pandemic vaccine becomes available in your area, I urge you to get it – for yourself, your family & your community. In the meantime, continue to practice good hygiene and social distancing.

Stay safe

Best regards

               Dennis

Dennis Osmer
Environment, Health, Safety,
& Emergency Management
www.LinkedIn.com/in/dennisosmer
HSE-exec@charter.net
678-421-4452

We discussed the use of checklists in the medical industry in a previous blog entry.  Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University.  He was selected in 2008 as Time Magazine’s Top 100 Most Influential People.  He had a great discussion on the use of checklists in medical industry, specifically hospitals.  He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists.  He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed.  Quite a statement!  Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development.
What do you think?  With so much research indicating the benefits of checklists, why have they not yet come into widespread use?

Eric was released from jail (a six month sentence for a medical error) on February 15.

Here’s the CNN video…

What do you think? Will Eric Cropp’s jail time make patients safer?

Here’s a medical example of 5-Whys. Tell me what you think…

A patient had the wrong leg amputated

1. Why Patient gave consent for amputation the night before the proposed

surgery to Registrar (who was not going to undertake procedure).

2. Why Amputation site marked with a biro (wrong leg).

3. Why Registrar unaware of hospital policy on amputation sites

being marked with a skin pencil and with bodily part being fully

visible to Doctor.

4. Why the department had no induction procedures for

new medical staff working in the department.

5. Why because “we’ve never been asked to”.

I’ll give my opinion after others have weighed in.