Category: Medical/Healthcare

Medical Humor May Explain Difficulties in Root Cause Analysis

January 14th, 2016 by

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?”

watson_medical_algorithm

What do you think? Leave your comments below.

 

How Can TapRooT® Help Prevent Falls and Maintain a Fall Prevention Program?

January 7th, 2016 by

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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:

ProactiveFlow

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!

Healthcare and the 3 Standard Corrective Actions

December 30th, 2015 by

 

Are you asking these two questions?

Are you asking two questions?

In all industries people struggle to create effective, measurable corrective actions. Many times we fall back to our standard ways of thinking and do what has been comfortable no matter the effectiveness we have seen in the past. In our courses we discuss the three “Standard” corrective actions:

  1. Training. Retrain everyone, not just those involved.
  2. Policies/Procedures. Write new policies or procedures or make the current ones longer.
  3. 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.

Why Healthcare Root Cause Analyses Fail

December 16th, 2015 by

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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.

CFOnly

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.

FullInvData

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.

Learn more about TapRooT® here or contact us to find out how TapRooT® is the answer to succeeding in your healthcare root cause analyses.

Friday Joke: Not Encouraging

November 27th, 2015 by

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.

Did you know it is “International Clean Hands Week”?

September 22nd, 2015 by

NewImage

Henry the Hand brings you the “T Zone Teaching Moment.”

Here is the video …

Visit this web site for more information:

http://www.henrythehand.com/healthful-tips/t-zone-teaching-moment/

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

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….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. 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:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. 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?

What is the burden of unsolved problems at your company?

May 4th, 2015 by

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:

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:

http://www.taproot.com/taproot-summit/register-for-summit

Southlake Hospital Staff Lives Their Values

March 24th, 2015 by

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:

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

NEW Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement

March 11th, 2015 by

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.

Skompski.Ed
Ed Skompski,Vice President
System Improvements

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:

http://www.taproot.com/taproot-summit/register-for-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

How Do We Stop the Ebola Blame Game?

October 27th, 2014 by

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:

http://blogs.reuters.com/great-debate/2014/10/27/why-finger-pointing-about-ebola-makes-americans-less-safe/

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?

Root Cause Analysis Video Tips: How TapRooT® Can Help with The Joint Commission Requirements

October 15th, 2014 by

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.

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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.)

Doctors Make Mistakes. Can We Talk About That?

June 9th, 2014 by

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.

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that

(This post was submitted by Jordan Harless, Healthcare Research and Development Associate, System Improvements, Inc.)

 

Tips for Avoiding Healthcare Errors

May 27th, 2014 by

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.

http://www.browardhealth.org/?id=1006&sid=1

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:

http://www.taproot.com/courses#2-day-incident

Monday Accident & Lessons Learned: Sentinel Event Discipline or Root Cause Analysis

May 12th, 2014 by

Watch this video and see how TapRooT® could have been used for root cause analysis…

Monday Accident & Lessons Learned: What Can We Do About Unnecessary Deaths by Error at Hospitals?

April 21st, 2014 by

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:

http://patientsafetyamerica.com

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?

What Should You Do To Improve Patient Safety & Healthcare Quality?

March 5th, 2014 by

My Mom suffered a sentinel event at a hospital in Illinois. Many of the readers here may have had loved ones who died or were significantly injured by mistakes at a hospital. But what can we do to improve patient safety and healthcare quality? Attend the Improving Healthcare Quality & Patient Safety Best Practice Track at the 2014 Global TapRooT® Summit.

When your mom is injured in a hospital sentinel event, you take performance improvement even more seriously. But I started the Improving Healthcare Quality & Patient Safety Best Practice Track back in 1995 – long before sentinel events and patient safety became front page news (and before my mom was injured). But why am I explaining my personal link to this track at the Summit? Because I want you to know how important this session is and how hard we work to bring valuable information to healthcare professional who attend the Summit.

What will you learn as a healthcare professional at the 2014 Global TapRooT® Summit? First, you will take back valuable best practices from these best practice sessions:

  • Error Proof Healthcare – How to Accelerate Your Improvement Efforts
  • The Emily Jerry Story: From Tragedy to Triumph
  • High Reliability Industry Lessons for healthcare
  • Slips, Trips, and Falls: The Science Behind Walking
  • Fatigue & Human Performance: The Tell-Tale Signs of Fatigue Related Mistakes
  • System Root Cause Analysis of Intergenerational Issues
  • Advanced Causal Factor Development
  • Expert Facilitation of Investigations Using TapRooT® Software

But that’s not all. You will also be motivated by our keynote speakers:

  • Christine Cashen – Why Briansorm When You Can Brain El Niño?
  • Carl Dixon – A Strange Way to Live
  • Mark Paradies – World Class Performance Improvement
  • Edward Foulke – Sweeping Workplace Safety Changes
  • Rocky Bleier – Be the Best You Can Be

But there’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility. 

Don’t miss out on this valuable opportunity to save patient’s lives and improve quality at your hospital. Register today at:

https://www.taproot.com/taproot-summit/register-for-summit

If you are a healthcare professional involved in patient safety and quality improvement, you really need to be there.

New Report: Hospital Errors are the Third Leading Cause of Death in the US and Improvement is Too Slow

October 31st, 2013 by

The Leapfrog Group issued a press release about hospital safety scores that once again showed that errors in hospitals are deadly and that improvement of patient safety is occurring too slowly. See the press release at:

http://www.hospitalsafetyscore.org/hospitalerrors-thirdleading-causeofdeathinus-improvementstooslow

Here is more discussion about the most recent rating results:

http://www.healthleadersmedia.com/page-1/HEP-297622/Leapfrog-Releases-Another-Hospital-Safety-Report-Card

And here is a site where you can look up the ratings of the hospitals near you:

http://www.hospitalsafetyscore.org/

What can you do to start improving performance at your hospital? Advanced root cause analysis – TapRooT® – can tell you what needs to be fixed.

Learn how TapRooT® can help your hospital improve patient safety by attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Here’s our upcoming worldwide course schedule:

http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training

Just click on your continent to see courses closer to you.

And if you are already TapRooT® Trained, attend the Improving Healthcare Quality and Patient Safety Track at the 2014 Global TapRooT® Summit near Austin, Texas. See the track topics by clicking on the fourth button in the left column at:

http://www.taproot.com/taproot-summit/summit-schedule

You will learn best practices from other hospitals and from other industries from around the world.

How Many People Die in the USA From Errors During Care?

September 21st, 2013 by

We’ve seen old estimates indicating that 98,000 people per year and 180,000 people per year die because of mistakes made during care that contributed to their deaths. Now a new study says the number may even be higher. It could be as much as 210,000 to 440,000 per year.

Does that get your attention?

Read about the new estimate that came from the  Journal of Patient Safety at:

http://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals

If your at a healthcare facility, consider using TapRooT® as part of your patient safety improvement program. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course to get started. Get course details and see the course schedule at:

http://www.taproot.com/courses#5-day-root

Food Manufacturing Alert: Metal Objects Found in Doughnut . How Would You Investigate It?

August 27th, 2013 by

donut Material found in a doughnut, see the initial indications from the KAKE media article below. A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth. “There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother. The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here. The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened.  Now what? Is this a safety or quality issue or both? If you were the retailer what would you do? Would you quarantine the doughnut and ask for access to the material found in the stomach? Would you be allowed? If you were the doughnut supplier what would you do? Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed? If you were the doughnut manufacturer what would you do? Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported? For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts? Everything just discussed would be part of the analysis/investigation planning stage.  The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available. What is Root Cause Analysis? Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results) Our public course schedule

Do Tired Surgeons Risk Patients’ Safety?

July 24th, 2013 by

I find it hard to believe that this question needs to be asked. Of course fatigue can lead to human error. This has been proven over and over again. And doctors are human.

I read an article in the Ploughkeepsie Journal that had the following quote:

While surgeons interviewed in a 2011 Georgia Regents University study believe fatigue has an effect on their ’emotions, cognitive capability, and fine-motor skills,’ few of them said it has a large effect on patient safety.

Obviously surgeons, just like many other workers, convince themselves that they can use willpower to overcome  the real physical limitations that fatigue creates. Physical limitations that lead to increased errors and patient harm.

Of course, everyone has some degree of fatigue in life. But the level of fatigue we are talking about goes above and beyond what could be deemed acceptable.

Is it possible to predict when someone will be too fatigued to produce reliable results? Yes. We worked with Circadian Technologies to help create their Fatigue Accident Causation Testing System (FACTS). Learn more about it at this link:

http://facts.circadian.com/index.html

I believe fatigue is one of the most underreported accident patient safety incident causes, Why? Because people don’t understand how insidious fatigue is as an accident cause.

No matter what industry you are in, if you would you like to learn more about fatigue as a cause of human error, attend the 2014 Global TapRooT® Summit and hear Bill Sirois, COO at Circadian Technologies, present “Fatigue and Human Performance – The Tell-Tail Signs of Fatigue Related Mistakes” in the Human Error Reduction and Behavior Change Track. You will return to work with a heightened awareness of the risks presented when people go beyond their limits of fatigue.

Friday Joke: Rounding Queen!

July 12th, 2013 by

For healthcare professionals .. a reminder.

For the rest of us … a Friday Joke!

New Personal Healthcare Device Tracks Vital Signs

May 22nd, 2013 by

The new Scanadu Scout is being promoted as a device that can help anyone conduct their own physical exams from the comfort of their own homes. The device reportedly tracks your vital sign, temperature, ECG, heart rate, even stress.  According to the company’s website, you can use the device to scan your body and “learn ways that different people, locations, activities, foods, beverages, and medicines affect your body.”

Mashable reports that “On a basic level, you can see that your temperature or heart rate is elevated from the norm at any given time. On a larger level, you can also see potential problems headed your way by noticing abnormalities before they become physical issues.”

What do you think? Will this help people get to the root cause of medical issues or simply identify symptoms? Will users understand how to interpret the results? Will people come to rely on it too much as a proactive healthcare tool and feel annual exams are not necessary?

 

 

Root Cause Analysis Used as an Important Tool to Identify Patient Safety Best Practices

March 7th, 2013 by

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.

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Authors

Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski

Medical

Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed

Equifactor®

Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

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