Category: Medical/Healthcare

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.

===============

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.

Proven Ideas to Improve Patient Safety

March 6th, 2013 by

The Agency for Healthcare Research and Quality published a research product that suggested proven ways to improve patient safety. Here were the best methods (strongly encouraged) from the study:

  • Preoperative checklists and anesthesia checklists to prevent operative and post-operative events.
  • Bundles that include checklists to prevent central line-associated bloodstream infections.
  • Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
  • Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
  • Hand hygiene.
  • “Do Not Use” list for hazardous abbreviations.
  • Multicomponent interventions to reduce pressure ulcers.
  • Barrier precautions to prevent healthcare-associated infections.
  • Use of real-time ultrasound for central line placement.
  • Interventions to improve prophylaxis for venous thromboembolisms.

For the complete study, see:

http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyII-full.pdf

Healthcare Scandal in UK – Calls for Major Improvements in Patient Safety and Criminal Prosecution of “Wrongdoers”

February 24th, 2013 by

Here’s a link to one of many stories about the “scandal” at UK hospitals in the Midlands:

http://www.guardian.co.uk/society/2013/feb/06/mid-staffordshire-report-sweeing-changes

The story says that “…up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital.”

Here’s a link to the Executive Summary of the report referred to in the article:

http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

Here’s a page where you can download the entire report:

http://www.midstaffspublicinquiry.com/report

The reports are extensive and I haven’t yet been able to wade through them (many volumes and 290 recommendations).

Here’s a press conference by the Chair of the Inquiry, Robert Francis QC:

The problems reported certainly do seem shocking. The problems are obviously systemic (generic) and seem to be related to the organization. The call for culture change seems obvious, but how to change the culture will be difficult. The problem for patients is the lack of choice (there is only one NHS) so that patients can’t “vote with their feet” when the standards of care become substandard.

The popular press and political outcry is calling for increased regulation and criminal prosecution of those who violate the rules. This seems close to the standard blame game and may succeed temporarily until the increased scrutiny eventually succumbs to complacency. This seems common in organizations with a monopoly on a certain service or product.

It seems to me that competition from hospitals trying to win additional patients would be the ultimate culture change recommendation. However, it is unlikely that this approach could be taken since the UK has had a single national service for so long.

Being in the UK when the story was receiving so much press, I was constantly being asked about how one would find the root causes of patient safety relayed problems. Of course, I described how healthcare organizations in the US use TapRooT® to investigate sentinel events. In the US, patient safety is becoming a competitive advantage – a way that hospitals may compete for patients.

What does your hospital do to ensure the highest standards of patient safety? Does your root cause analysis find and fix the root causes of patient safety problems? Does your management require advanced root cause analysis and insist on the implementation of effective corrective actions to sentinel events? Can you show the improvement in patient safety through the use of advanced trending tools?

Those interested in improving patient safety should consider attending the Improving Healthcare Quality and Patient Safety Track at the 2013 Global TapRooT® Summit in Gatlinburg, TN, on March 20-22. For more Summit information see:

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

And for the track’s detailed schedule, see:

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

and click on the button on the left for the track specific schedule.

For those in the UK, changes as great as those described will be difficult and take tremendous effort. I wish you luck but advise you that thorough advanced root cause analysis and effort will be required on a continuing basis if progress is to be made.

A Surefire Way to Keep Your Valentine’s Day Fun: Keep It Safe.

February 14th, 2013 by

The best way to keep your Valentine’s Day romantic and fun? Make food safety a priority!

A recent article on StateFoodSafety.com notes that the best restaurant to eat in on Valentine’s Day is a clean one. Here are a few of their food safety tips this Valentine’s Day:

  • Take note of the dining area and restrooms. If they do not meet cleanliness standards, it’s probably a good sign that the kitchen is also in need of more than just a light dusting. You might consider eating elsewhere for your own safety.
  • Only eat foods that are served to you hot. If the food is served to you at a lukewarm temperature, chances are that it was left sitting for too long and has allowed harmful bacteria to multiply.
  • Make sure the staff does not touch your food or the tips of your silverware with their bare hands. It’s probably not a good idea to let them sample your drink either.
  • Be wary of meat, eggs, oysters, or other raw foods that are undercooked.
  • Wash your hands properly before and after eating.

Click here to read the full article.

Photo courtesy of NPR.

Why doesn’t training prevent medical accidents?

February 11th, 2013 by

How many times have you seen a corrective action to “conduct more training”? Why is this often such a poor corrective action?

Unfortunately, even highly-trained people can make mistakes. A recent article illustrates this nicely.

Link

If you haven’t seen the “basketball” video before, take a look at it at the link above.

This article describes how highly-trained radiologists, people who have an incredible eye for detail, can still make glaring errors based on what they are asked to do. It’s a great example of why “training” may not always be the best corrective action.

Monday Accident & Lessons Learned: What is Your Hospital Doing to Fight Medical Mistakes?

September 24th, 2012 by

 Public Resources Images Rv-Ai221 Hospit G 20120921010937

Interesting article in The Wall Street Journal. The first two paragraphs read:

When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.

The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers.

The article missed one important advanced but simple idea. Use TapRooT® to find and fix the causes of medical errors and use TapRooT® proactively to prevent them in the first place.

If you don’t know how TapRooT® can help your hospital, you should attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and find out. Start saving lives today!

Monday Accident & NOT Lessons Learned: Under-Reporting of Sentinel Events May Be One More Cause of Failure to Prevent Human Errors in the Healthcare Setting

February 20th, 2012 by

A new investigation by the Inspector General of the Department of Health and Human Services says that:

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized.

The report also says that:

…even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the ‘adverse events.’

For the whole report, see:

http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf

So, only a small fraction of sentinel events are investigated and most of those don’t cause permanent, effective change to prevent future errors.

Sometimes it can be frustrating to be a prophet when those that could make change happen just don’t listen. We’ve been suggesting proven ways to improve sentinel event investigation and performance improvement that could be applied by medical facilities ever sine the 1994 TapRooT® Summit. But only a limited number of healthcare facilities have taken advantage of the lessons they could learn.

The TapRooT® Summit is coming up on February 29 – March 2 and we have a full track devoted to improving performance in the healthcare industry. This isn’t just lessons from inside the industry. Rather, this is a place where healthcare folks can learn from a wide variety of industries and facilities with best practices from around-the-world.

If you are from a healthcare facility that needs to improve (and from the Inspector General’s report, that’s just about every facility) there’s still just enough time to sign up. See:

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

Why Are We Failing To Prevent Sentinel Events? By Mark Paradies

February 16th, 2012 by

Med

DEATH TOLL

What kills more people in the US than industrial accidents, highway accidents, and airline accidents combined?

Mistakes in hospitals.

The technical term for these mistakes is “Sentinel Events.”

Estimates of the deaths caused vary. We use estimates because there are no accurate statistics on the total number of deaths caused by mistakes in hospitals. There is no national reporting requirement.

Even though there is no national reporting requirement, studies show that despite over a decade of effort to stop sentinel events, no progress is being made. Some studies actually show the problem getting worse. And this problem isn’t unique

WHY NO IMPROVEMENT

Why can’t we improve? There are a number of factors that make improvement difficult:

1. Healthcare Complexity

2. Poor Root Cause Analysis (RCA)

3. Inadequate Corrective Actions

4. Not Enough Management Attention

We will review all of these factors and what we can do about them in the following sections.

HEALTHCARE COMPLEXITY

Medical practice keeps getting more complex. More complex technology. More drugs with more interactions. More pressure to work faster and be more efficient. The result? More chances to make errors with catastrophic consequences. At the same time, downsizing means less staff to catch errors.

Healthcare complexity calls for increased, proactive application of system reliability and human factors solutions to improve health¬care delivery.  Intelligent, resilient design can make complex systems reliable. Plus, staffing needs to be assessed to ensure adequate coverage to apply error-catching activities.

POOR ROOT CAUSE ANALYSIS

After a decade of using RCA to analyze sentinel events, the lack of progress indicates a failure of healthcare root cause analysis.

What’s wrong? A majority of healthcare facilities use inadequate RCA systems including fishbone diagrams, 5-Whys, and healthcare derived root cause checklists. These “simple” techniques are inadequate to analyze complex healthcare sentinel events.

Not only are the RCA systems inadequate, the RCA training is also inadequate. People are assigned to investigate healthcare sentinel events with little or no training. They are lucky to attend a free one to eight hour session provided at a professional society meeting or sponsored by an insurance provider.

But healthcare investigators face another factor that makes root cause analysis even more difficult: BLAME. More than your everyday blame that comes with every accident. Medical malpractice seems designed to make people less open – less willing to cooperate wholeheartedly with investigators.

Furthermore, doctors who are independent contractors are naturally suspicious of investigators who seem to question their judgment and put their credentials at risk. Is it any wonder that we haven’t made progress?

Despite some of the factors that are difficult to address, picking an advanced root cause analysis system and getting people trained shouldn’t be hard. After all, there is TapRooT®!

The TapRooT® System was designed to be used for simple and complex investigations. It has been applied successfully in healthcare settings and has improved performance of complex systems. The 2-Day and 5-Day TapRooT® Courses have been customized for on-site training of healthcare investigators to help them with demanding investigations. Problems solved!

POOR CORRECTIVE ACTIONS

Inadequate root cause analysis is just the start. Typically, we see the weakest corrective actions applied to prevent repeat sentinel events.

Those familiar with the terminology “hierarchy of controls” applied in industrial and process safety may know what I am pointing out. Healthcare corrective actions often include the application of new standards that depend on human reliability. When these fail, investigators recommend some of the “re” corrective actions, including: re-train, re-mind, and re-emphasize (discipline).

But these are the weakest possible corrective actions (see pages 127 -129 in your 2008 TapRooT® Book.) More effective corrective actions include another type of “re” corrective action. Removing the hazard or the target. Or, re-engineering the process to improve system reliability and decrease human error without adding additional tasks for people to cope with.

These types of corrective actions and more are the result of a TapRooT® investigation when investigators apply the suggestions in the Corrective Action Helper® and apply Safeguards Analysis as part of the development of their solutions.

MANAGEMENT ATTENTION

One might say that the cause of all the previous problems is inadequate management attention to performance improvement at healthcare facilities. Part of this inattention can probably be attributed to the fact that most healthcare administrators aren’t trained in advanced performance improvement techniques. Even the few who have had Six Sigma training don’t know about advanced root cause analysis and, therefore, don’t know about the action they could take to make performance improvement happen.

Plus, hospital administrators need to become more involved in the analysis, review, and approval of sentinel event investigations. Involvement can bring them face-to-face with the challenges people are experiencing in the field. Trained managers reviewing a SnapCharT® can see beyond blame to real action to improve performance. They can see their contribution to errors that come from understaffing and fatigue. They can become a knowledgeable part of the team fighting sentinel events.

SIMPLE PLAN TO IMPROVE

Each day, hundreds of lives are lost because we haven’t won the battle to defeat sentinel events. Don’t wait for the entire healthcare industry to wake up to the problems and solutions. Don’t wait for regulatory requirements to force your facility into action. Start today with the tools that are at hand.

1. Bring the message to management. Get them involved. They should feel that EVERY sentinel event at their facility is a personal failure to address the causes!

2. Adopt an advanced root cause analysis system – TapRooT® – including the latest root cause analysis software and database to help you learn from small incidents to prevent major sentinel events.

3. Get the training that your facility needs in root cause analysis. This includes training for hospital administrators, staff, and your performance improvement experts.

Start with a customized 2-Day TapRooT® Course for senior management. Follow that with a 2-Day TapRooT® Course for those who are frequently involved in sentinel event investigations and a 5-Day TapRooT® Course for those who facilitate sentinel event investigations.

4. Once you complete steps 1-3, you are ready to start continuous improvement efforts. Start by attending the TapRooT® Summit healthcare track to find out what other leaders in the field of healthcare are doing to continue improvement efforts.

Don’t wait. People are dying waiting for improvement to occur. Start today!

(Reprinted by permission from the February Root Cause Network™ Newsletter, Copyright © February, 2012)

Healthcare Quality, Patient Safety, and Sentinel Event Best Practices Track at the 2012 Global TapRooT® Summit

January 4th, 2012 by

Are you involved in performance improvement efforts in the healthcare industry? Then you should be planning to attend the 2012 Global TapRooT® Summit Track titled:

Healthcare Quality, Patient Safety, and Sentinel Event Best Practices

Most conferences about improving patient safety, healthcare quality, and reducing sentinel events are strictly organized by and attended by healthcare professionals. This provides good sharing of best practices within the healthcare industry, but does not provide networking or benchmarking outside the healthcare industry.

The TapRooT® Summit provides both in-industry networking/benchmarking and cross-industry/cross-functional networking/benchmarking. Here’s one healthcare industry patient safety professional talking about her experience at a previous Summit:

Marionchristiansen-2

(.wmv format. Click above to play)

But what about the 2012 Global TapRooT® Summit? There are several sessions at the 2012 Global TapRooT® Summit that have a strictly healthcare focus:

  • What does increasing expectations for healthcare quality and patient safety mean to your improvement efforts?
  • Response lessons learned from the Joplin Disaster.
  • Using electronic medical records to improve healthcare quality and patient safety.
  • Using Baldrige criteria to achieve performance improvement.

These provide opportunities to network and benchmark with healthcare professionals.

Plus, there are also sessions that span industries and disciplines:

  • Criminal prosecutions of accidents.
  • Developing a fatigue risk management plan.
  • Positive Contributions in facilitation and management interactions.

But that’s not all. The Keynote Speakers also provide lessons learned and best practices that cross industries.

For example, Astronaut Ken Mattingly, of Apollo 13 fame, talkes about Lessons Learned from Apollo 13 and Space Shuttle Operations.

 WordPress Wp-Content Uploads 2011 12 A16 Ken Mattingly-3

And Dr. Beverly Chiodo talkes about Character Driven Success and how it can help your improvement program.

 WordPress Wp-Content Uploads 2011 12 Chiodo.530-2

Also, there is a panel discussion of senior managers (Gerry Migliaccio, Senior VP at Pfizer; Vicki Hollub, President & General Manager of OXY Permian CO2 Business Unit; and Zena Kaufman, Divisional Vice President of Global Pharmaceutical Operation at Abbott Laboratories) who will discuss “What Does Senior Management Want from Incident Investigations and Root Cause Analysis?”

This is just a sample of the sessions, for the complete TapRooT® Summit schedule, see:

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

I know you will find the information you take home motivational and valuable. That’s why we provide the following Summit guarantee:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

With a guarantee like this one, you have nothing to lose and everything to gain!

Aurobindo Pharma taking their Root Cause Analysis to World Class Standards

December 13th, 2011 by

For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.

Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.

Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.

It was a pleasure to teach and work with this group personally in Hyderabad, India.

If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February.  Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.

Go here to register for the 2-day http://www.taproot.com/courses.php?d=1709&l=1

See the public courses and root cause articles for India:

http://www.taproot.com/content/archives/25773

http://www.taproot.com/content/archives/24854

http://www.taproot.com/content/archives/24348

http://www.taproot.com/content/archives/22733

http://www.taproot.com/content/archives/20033

The July Effect – Watch Out for New Interns in July!

July 12th, 2011 by

 Doctor-Looking-Concerned-About-Status-Of-Alcoholism-Patient

A study of 244,388 death certificates issued from 1979 to 2006 conducted by a doctor at the University of California, San Diego, and published in the Journal of General Internal Medicine showed that fatal medication errors increased by 10 percent in July in counties with teaching hospitals.

Why might this be?

Because many new residents (interns) arrive from universities in July.

New interns don’t have experience, don’t know who does what, are learning what it is to work in a hospital, and, especially in the past, may work really long hours.

David Wenner of The Patriot-News wrote about the problem and some comments by different hospital safety professionals and doctors in an article titled: “Hospital take steps to reduce errors among medical residents.”

What can you do as a patient?

First, check your medications closely.

Second, wait to get sick (or be hospitalized for any reason) until September when the new residents will be more seasoned!

Connect with Us

Filter News

Search News

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

Success Stories

Fortunately, I had just been introduced to a system for incident investigation and root cause analysis…

Enmax Corporation

We held our first on-site TapRooT Training in mid-1995. Shortly after the training we had another…

Intel
Contact Us