Category: Performance Improvement
Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):
Reviewing this data, one might ask …
What can we learn?
I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…
- Does a tic up or down in a particular category mean something?
- Why are suicides so high and infections so low?
- Why is there no category for misdiagnosis while being treated?
Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.
Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.
If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.
That makes me ask some serious questions.
1. Are the other events being hidden? Ignored? Or investigated and not reported?
Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?
2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?
To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database.
If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data.
This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.
This isn’t happening.
What can you do to get things started?
1. Push for full reporting of sentinel events AND near-misses at your hospital.
2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.
3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.
That’s a start. After twelve years of reporting, shouldn’t every hospital get started?
If you are at a healthcare facility that is
- reporting ALL sentinel events,
- investigating most of your near-misses,
- doing good root cause analysis,
- implementing effective corrective actions that
- stop repeat sentinel events,
I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.
If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.
Here’s a link to the announcement:
Here are the 11 tenants they suggest:
To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:
And then healthcare executives could also insist on advanced root cause analysis.
Ignorance is Bliss
From many people’s actions, you might believe that they think “ignorance is bliss” is true. We need to ignore the real root causes of problems and just attack the symptoms.
Even the cartoon, Calvin and Hobbs, commented on it. See the cartoon on my Facebook page …
Is this the way you treat your root cause analysis?
Would you rather have a simple BUT WRONG answer?
For over a decade, I’ve explained the shortcomings of 5-Whys for root cause analysis but some still believe that easy is better than right.
What if you could find and fix the real root causes of what you think are “simple incidents” with a robust, advanced system (TapRooT®) and not make a career of the investigation? You would put in only the effort required. Your investigation would be as simple as possible without going overboard. And your corrective actions would be effective and stop repeat incidents.
That’s what the new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about.
Have you read the new book yet?
Once you read the book you will want to start implementing TapRooT® for all the “simple” investigations that are worth being done.
Get the book today and find out what you should be doing. Order the book at:
This all sounds good for the US oil sector. It is expected that hiring will start picking up, and in fact Jeff Bush, president of oil and gas recruiting firm CSI Recruiting, has said, “When things come back online, there’s going to be an enormous talent shortage of epic proportions.”
So, once you start hiring, who will you hire? Unfortunately, much of the 170,000 oil workers laid off over the past couple of years are no longer available. That experience gap is going to be keenly felt as you try to bring on new people. In fact, you’re probably going to be hiring many people with little to no experience in safe operation of your systems.
Are you prepared for this? How will you ensure your HSE, Quality, and Equipment Reliability programs are set up to handle this young, eager, inexperienced workforce? What you certainly do NOT want to see are your new hires getting hurt, breaking equipment, or causing environmental releases. Here are some things you should think about:
– Review old incidents and look for recurring mistakes (Causal Factors). Analyze for generic root causes. Conduct a TapRooT® analysis of any recurring issues to help eliminate those root causes.
– Update on-boarding processes to ensure your new hires are receiving the proper training.
– Ensure your HSE staff are prepared to perform more frequent audits and subsequent root cause analysis.
– Ensure your HSE staff are fully trained to investigate problems as they arise.
– Train your supervisors to conduct audits and detailed RCA.
– Conduct human factors audits of your processes. You can use the TapRooT® Root Cause Tree® to help you look for potential issues.
– Take a look at your corrective action program. Are you closing out actions? Are you satisfied with the types of actions that are in there?
– Your HSE team may also be new. Make sure they’ve attended a recent TapRooT® course to make sure they are proficient in using TapRooT®.
Don’t wait until you have these new hires on board before you start thinking about these items. Your team is going to be excited and enthusiastic, trying to do their best to meet your goals. You need to be ready to give them the support and tools they need to be successful for themselves and for your company.
TapRooT® training may be part of your preparation. You can see a list of upcoming courses HERE.
I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.
Blame is the number one reason for bad root cause analysis.
Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.
As Bart Simpson says:
“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”
Blame is so common that people take it for granted.
Somebody makes a mistake and what do we do? Discipline them.
If they are a contractor, we fire them. No questions asked.
And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.
Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?
But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.
Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution.
How do you stop blame and get people to cooperate with investigations? Here are two best practices.
A. Start Small …
If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous.
Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.
B. Use a SnapCharT® to facilitate your investigation and report to management.
We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.
Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame.
What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:
2. FIRST ASK WHAT NOT WHY
Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.
Because they should have started by asking what before they asked why.
Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem.
How do you get people to ask what instead of why?
Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.
3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE
Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.
What happens when an investigator starts an investigation by jumping to conclusions?
They ignore evidence that is counter to their hypothesis. This problem is called a:
It has been proven in many scientific studies.
But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.
What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?
Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.
How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.
The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.
If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.
If your organization faces:
- Quality Issues
- Safety Incidents
- Repeat Equipment Failures
- Sentinel Events
- Environmental Incidents
- Cost Overruns
- Missed Schedules
- Plant Downtime
You need to be apply the best root cause analysis system: TapRooT®.
Learn more at:
And find the dates and locations for our public TapRooT® Training at:
Did you make your New Year’s resolutions? Your ideas to improve your performance next year?
In many companies, you are expected to have plans to improve performance. Better production performance, quality, equipment reliability, safety, process safety, and financial performance are all expected parts of the normal year-to-year improvement process. If you are leading any of these improvement efforts, you better have a plan.
What if you could do something to both improve your personal performance and your company’s performance? Would that be interesting?
Plan to attend a TapRooT® Root Cause Analysis Course!
What are you waiting for? TapRooT® Root Cause Analysis is proven by leading companies around the world to help them find and fix the root causes of performance problems. And the TapRooT® System can be used proactively to stop problems before major incidents happen. This can lead to improved financial performance in addition to improved safety, quality, equipment reliability, and production performance.
But beyond that, you will be adding an advanced skill to your toolbox that you can use for the rest of your career. Think of it as a magic problem-solving wand that you can use to astound others by the improvement initiatives you will lead. This can lead to promotions and personal financial gain. Sounds like a great personal improvement program.
Now is the time to make your plans for 2017. Get your courses scheduled. Get ready to make your skills better and your company a better place to work.
Read this story about a recent BP internal audit:
You can see why many managers don’t want written reports critical of any safety or environmental performance.
Does your company have any practices to mitigate bad press from internal audits?
If you don’t understand what happened, you will never understand why it happened.
You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?
I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.
Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.
If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?
This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.
The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.
TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.
Foe course information and course dates, see:
I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:
“If people would just try harder, be more careful, or be more alert, the problems would go away.”
This implies bad people (careless, lazy, and/or dullards) are the issues.
Have you ever met one of these people? Do you work in an organization that thinks this way?
I once had a safety manager at a refinery tell me:
“At our refinery, 5% of the people account for 95% of the lost time injuries.”
He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.
Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.
TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.
Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.
And don’t worry about trying something new. Our courses are guaranteed!
Attend our training, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software and
we will refund the entire course fee.
That’s a strong guarantee because we know that TapRooT® will work for your company.
For more information about TapRooT®, watch the video at:
Success teaches us nothing; only failure teaches.
Admiral Hyman Rickover
Every hour has sixty golden minutes,
each studded with sixty diamond seconds.
Admiral Hyman Rickover
I saw this picture today, and I thought about how people often make decisions based entirely on direct cost. For some things, we make a deliberate analysis of the long-range costs, benefits, and applicability of a product. For example, when we buy a new car, we might decide to pass on a particular brand of vehicle based on what we know (or at least, what we have heard) about the quality of that vehicle, its features, its reliability, and the fit to what we need. Remember the Yugo? I don’t see many of them on the road any more!
And yet, when we are making the decision on the best way to improve the health and safety of our coworkers, we seem to jump right on, “What does it cost?” I heard someone in Australia just the other day tell me about an RCA “methodology” that is being evaluated for use in some for their critical improvement programs. I asked why they were considering this other method. Does it work better? The answer made me sad. “Well, no, we don’t think it works as well as TapRooT®. Using [this other system] gives pretty ambiguous results, depending on who is using it. But it’s a little bit cheaper, so my manager wants to go that way.”
This doesn’t seem to make a lot of sense to me. If you can save 10%, but get poor results, what have you actually saved? I encourage you to look at the costs of even a single “simple” incident, and then bounce that against a few percent savings in poor-quality training. I think you’ll find that the initial savings are lost in the noise.
You wouldn’t buy a car based solely on price. I encourage you to take the same due diligence when you are selecting an RCA program that has the potential to save the lives of your teammates.
I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.
How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.
Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances. It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.
When you waste your time remember …
Even God cannot undo the past.
Admiral Hyman Rickover
The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…
IOGP SAFETY ALERT
CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE
Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.
A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.
What Went Wrong?
The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).
- The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
- Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
- The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
- In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
- Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
- In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.
Corrective Actions and Recommendations:
Lessons Learned –
- As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
- The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.
Action taken in originating company –
Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.
- A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
- The temporary suspension does not cover retrieval operations on lines which are depressurised.
* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
Safety Alert Number: 273
IOGP Safety Alerts http://safetyzone.iogp.org
At this school, the smartest work as hard
as those who must struggle to pass.
Admiral Hyman Rickover
The secret of success:
late to bed,
early to rise,
work like hell and you’ll be wise.
Admiral Hyman Rickover
Heaven is blessed with perfect rest.
The blessing of earth is toil.
Admiral Hyman Rickover
Download this Excel® Spreadsheet to your laptop or other device to participate in the exercise in the “Grade Your Investigation” Best Practice Session at the 2016 Global TapRooT® Summit:
This Accident shares a “Call Back” Report from the Aviation Safety Reporting System that is applicable far beyond aviation.
In this case, the pilot was fatigued and just wanted to “get home.” He had a “finish the mission” focus that could have cost him his life. Here’s an excerpt:
I saw nothing of the runway environment…. I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had so many times in past years. The only conscious control input that I can recall is leveling at the MDA [Rather than continuing to the DA? –Ed.] while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at the flight instruments as I began…an uncontrolled, unconscious 90-degree turn to the left, still looking for the runway environment.
To read about this near-miss and the lessons learned, see:
Rickover talking about his famous candidate interviews …
You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?
Is this the best approach to preventing future problems? NO! Not by a long shot.
We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:
- Wacky Willie
- Will Discipline Fix the CTA’s Problems?
- USS Hartford / USS New Orleans Collision & Subsequent Discipline
- Should You Discipline BEFORE an Investigation is Complete?
- What Should Managers Know About Root Cause Analysis?
- Root Cause Analysis – Do it before even thinking about discipline!
Let me sum up what we know …
Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.
In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.
For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses