Monday Accident and Lessons Learned: What Can Happen When Management Doesn't Demand Complete Root Cause Analysis and Follow Up with Effective Corrective ActionsPosted: January 24th, 2011 in Current Events, Investigations, Medical/Healthcare, Performance Improvement, Quality, Video
Watch this video …
Job Opening: Salt Lake City, UT – University Hospital – Quality Specialist – Needs Root Cause Analysis SkillsPosted: January 16th, 2011 in Job Postings, Medical/Healthcare
Ever thought about volunteering to be a test subject for medicine….. would you be concerned if you were in phase 1 of a new drug trial?
Listen to this pod cast where the standard practice become a practice because no one had become very ill until this study. Each reinforcing non-injury becomes the reinforcement that this must be a good process.
Select the link below to listen.
What do you do with unexplained discrepancies? FDA uncovers more problems at J&J Fort Washington plantPosted: December 16th, 2010 in Accidents, Current Events, Investigations, Medical/Healthcare, Performance Improvement, Quality, TapRooT
“In an inspection report released late on Wednesday, the Food and Drug Administration said a recent visit uncovered multiple quality control problems, including a failure to properly handle customer complaints.”
“Inspectors also found “a failure to thoroughly review any unexplained discrepancy” in batches of products and a lack of proper record keeping, according to the report from an inspection that ran from October 27 to December 9.”
The Washington Plant is closed and the article reports that J&J has continued making improvements. The question is whether the handling of unexplained discrepancies is unique to this industry?
In the US Air Force we named it CND, “Could Not Duplicate”; A CND could only be signed off in the aircraft forms by the appropriate personnel. If a CND occurred three times on the same aircraft, the aircraft was grounded.
What is your Industry Rule? (more…)
Okay. I often talk about the Doctors of Tomorrow will be the Pilots of Today. With the increase use of Aviation and Nuclear tools such as Crew Resource Management and the use of Checklists for Pre-Op or Post-OP, we are seeing changes in Medical Error every day. But then I see someone trying to take a short cut…..
“He seemed like Superman, able to guide jumbo jets through perilous skies and tiny tubes through blocked arteries. As a cardiologist and United Airlines captain, William Hamman taught doctors and pilots ways to keep hearts and planes from crashing.”
“His pilot qualifications do not appear to be in question — he holds the highest type of license a pilot can have, a Federal Aviation Administration spokeswoman said. However, United grounded him in August after his medical and doctoral degrees evaporated like contrails of the jets he flew.”
…and then here is one of the first responses after finding out, “Even after learning of Hamman’s deception, the American Medical Association was going to let him lead a seminar that had been in the works, altering his biography and switching his title from “Dr.” to “Captain” on course materials. It was canceled after top officials found out.”
“He really didn’t need to be a physician to do what he was doing. He could have been successful without titling himself,” said Weaver of the cardiology college. “He made a very serious mistake.”
Lesson learned: You can help people be successful with Truth. Something we do everyday with TapRooT® Root Cause Analysis in all industries.
RCA in India: Do not miss the February 2011 5-Day TapRooT® Advanced Root Cause Analysis Team Leader TrainingPosted: December 2nd, 2010 in Accidents, Courses, Human Performance, Investigations, Medical/Healthcare, Performance Improvement, Pictures, Root Causes, 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.
1. You get the benefit of our course in India without needing 10 of your people trained at the same time.
2. You do not have to fly your India based employees to another country to be trained.
3. If you are one of our international customers, you do not have send one of your trained investigators to India to complete an Investigation for defects, incidents or sentinel events.
4. Because the students will receive individual software to document their findings, you will receive a consistent report.
Register today to make sure your employee does not lose a seat in the course.
With so much recent interest from India based companies to hold an onsite course in India, we decided to hold a possible public course February in Mumbai.
Companies in India new to TapRooT® are not always ready to set up an onsite class for 10 or more employees until they see what they can do with what they learn. With enough interest and commitment from you, we will have a 5-day public course.
Please contact firstname.lastname@example.org or email@example.com and let us know how many employees you want to send to the course.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
Description: Learn all the TapRooT® tools, and also many advanced skills that a Team Leader needs to collect information, analyze root causes, and develop effective fixes that will help your company improve performance.
Course Fee: $2,395 USD plus GST/VAT
3 or more attendees, each save:-$100
Fee Includes: Includes TapRooT® single user software, TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.
Who Should Attend: Environment, Safety, and Health Managers Quality Managers, Hospital Risk Managers, Hospital Quality Assurance Professionals, Equipment Root Cause Experts, Governement Regulatory Investigators (MSHA, OSHA, EPA, UK HSE, FAA, FRA, MMS, NRC, DOT, DOE, CSB, NTSB, …) Safety Engineers, Coordinators, Professionals Reliability & Maintenance Engineers, Design Engineers, Facility Managers, Quality Auditors.
If you want to be the root cause analysis expert at your company, then this course is for you. This course is especially valuable for people interested in analyzing the causes of human error. You’ll earn rules and theories to help you improve human performance, including how to improve procedures, training, communications, human engineering, supervision, and management systems. You’ll also learn ways to improve your company’s investigation processes and procedures.
Senior Associate, Instructor
Six Sigma Black Belt
System Improvements, Inc.
1.865.539.2139 ext. 106
TapRooT® Changing The Way The World Solves Problems
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:
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:
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:
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:
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:
Can an equipment issue and an operations problem cause a quality issue that causes a sentinel event?
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:
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:
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).”
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:
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)…..
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.
A TapRooT® User passed along an article about doctor fatigue. His comment? The medical industry really needs TapRooT®.
Here’s the article:
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:
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…