Category: Medical/Healthcare

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:

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:

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

February 16th, 2012 by



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 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.


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.


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!


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.


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.


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:


(.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.

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

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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:

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

See the public courses and root cause articles for India:

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

July 12th, 2011 by


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!

Job Opening: Los Angeles, CA – UCLA Health System – Root Cause Analysis Program Coordinator

July 6th, 2011 by

The posting says:

In this position, you’ll help oversee the design, planning and coordination of our Root Cause Analysis Program, which is focused on the investigation of patient safety issues. Responsibilities include recommending and coordinating error reduction efforts to minimize safety issues and risk within our healthcare system; helping facilities integrate system design improvements using human factors engineering principles; identifying and addressing barriers to the implementation of safety-enhancing practices; and conducting educational presentations that facilitate the understanding and implementation of patient safety within the organization.

For more information, see:

What is the impact of an incident?

June 27th, 2011 by

Very sad story:

Many times when we think of the cost of incidents we think in terms of dollars.  But let us never forget the human cost as well.  One mistake can affect the lives of many families.

Checklist for Checklists

June 21st, 2011 by

Dr. Atul Gawande at Brigham and Women’s Hospital and several associates developed this “Checklist for Checklists” for use at hospitals…

Checklist For Checklists Group Draft 5

Great stuff. Check out his web site at:

Eric Cropp Sentenced

May 31st, 2011 by

This was the scene at Eric Cropp’s sentencing hearing…

Hear him talk about the mistakes he made and the criminal prosecution at the TapRooT® Summit.

How Much Do Errors Cost at Your Company? In the Healthcare Industry in the US, the answer is $17 BILLION Dollars!

April 26th, 2011 by

 Images Medical-Error

Here’s the article that the number above comes from:

Do you know the answer for your site/company?

If you don’t know, how do you judge how much you should be spending to improve performance?

By the way … how much has the healthcare industry progressed since the picture above in the technology of preventing human errors?

Retraining is the Solution to a Toddler receiving a mixed drink instead of juice?

April 12th, 2011 by



Alcohol or Juice?

Interesting article today titled: “Restaurant to retrain staff after mixed-drink mixup”

On Friday, Taylor Dill-Reese went to an Applebee’s in Madison Heights, Michigan, where — among other things — she ordered her 15-month-old son Dominick an apple juice.

What the little boy apparently got instead was a margarita. His mom told WDIV-TV that she only realized something was wrong when Dominick “kind of laid his head on the table and dozed off a little bit and woke up and got real happy.”

The little boy reportedly began hailing strangers, too.

According to the article the restaurant stated, that it would begin to serve apple juice to children only from single-serve containers at the table and would “retrain all severs on our beverage pouring policy, emphasizing that non-alcoholic and alcoholic beverages must be stored in completely separate and identified containers.”

…. for our TapRooT® trained investigators, can you think of any other root causes than training?

A Medical Tale: When following the current standard practice can kill you!

December 28th, 2010 by

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 plant

December 16th, 2010 by

“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…)

RCA in India: Do not miss the February 2011 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

December 2nd, 2010 by

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.

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The benefits:

1. You get the benefit of our course in India without needing 10 of your people trained at the same time.

2. You do not have to fly your India based employees to another country to be trained.

3. If you are one of our international customers, you do not have send one of your trained investigators to India to complete an Investigation for defects, incidents or sentinel events.

4. Because the students will receive individual software to document their findings, you will receive a consistent report.

Register today to make sure your employee does not lose a seat in the course.

Mumbai, India Feb 21 – Feb 25 Register

5-Day TapRooT® Public Course with Software Included Feb 21-25, 2011 in Mumbai, India

November 1st, 2010 by

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 or and let us know how many employees you want to send to the course.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Description: Learn all the TapRooT® tools, and also many advanced skills that a Team Leader needs to collect information, analyze root causes, and develop effective fixes that will help your company improve performance.

Course Fee: $2,395 USD plus GST/VAT
3 or more attendees, each save:-$100

Fee Includes: Includes TapRooT® single user software, TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.

Who Should Attend: Environment, Safety, and Health Managers Quality Managers, Hospital Risk Managers, Hospital Quality Assurance Professionals, Equipment Root Cause Experts, Governement Regulatory Investigators (MSHA, OSHA, EPA, UK HSE, FAA, FRA, MMS, NRC, DOT, DOE, CSB, NTSB, …) Safety Engineers, Coordinators, Professionals Reliability & Maintenance Engineers, Design Engineers, Facility Managers, Quality Auditors.

If you want to be the root cause analysis expert at your company, then this course is for you. This course is especially valuable for people interested in analyzing the causes of human error. You’ll earn rules and theories to help you improve human performance, including how to improve procedures, training, communications, human engineering, supervision, and management systems. You’ll also learn ways to improve your company’s investigation processes and procedures.

Best Regards,

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

System Improvements, Inc.
1.865.539.2139 ext. 106

TapRooT® Changing The Way The World Solves Problems

Medical Accidents (Sentinel Events) in the UK

October 26th, 2010 by

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

Video of Nurse Error

Mother Died of Mix Up

Surgeon Cuts Off Testicle “By Mistake”

CNN Says “Surgery mix-ups surprisingly common”

October 19th, 2010 by

The story posted on 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:

More BAD Practices Being Taught as a Good Practices

October 7th, 2010 by

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:

Is Patient Safety Taking a Back Seat to Healthcare Reform?

October 6th, 2010 by

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.

Seattle Children’s Hospital has Multiple Sentinel Events – Is Root Cause Analysis Working?

October 1st, 2010 by

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.

Hospital Errors Under-Reported? This Article Says So!

September 27th, 2010 by

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:

Food Quality Issue Causes Baby’s Death – Deemed a “Medical Accident”

September 17th, 2010 by

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

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.

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