Category: Medical/Healthcare

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.

What Marion Christiansen Has To Say About The Summit (Patient Safety)

September 8th, 2010 by


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.

What Do Medical Errors Cost in the United States?

August 15th, 2010 by

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.

What a 5-Day TapRooT® Class in Gatlinburg, TN! Is your Industry really that different?

July 31st, 2010 by

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

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

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

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

Some more pictures from the course below.
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“Hands-only CPR, pushy dispatchers are lifesavers”

July 28th, 2010 by

Read more here:

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