Here’s a summary for reported sentinel events for the 2nd quarter of this year, compiled by The Joint Commission. It also compares some of the data against previous years.
It is almost impossible to make accurate comparisons on this data, since all reports are voluntary and, as stated in the report:
“Data Limitations: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. ”
Without knowing who is reporting, who is not reporting, how these numbers are compiled or arrived at, how the problem types are assigned, etc., I’m having a tough time viewing the data in an objective light.
While the data is interesting, I’m not sure how this data is used. Can anyone give me an example of how the data in this summary might be used?
– Required by regulators or law
– Required by company policy
– Perceived higher return on investment
However, companies often default to less developed (and therefore less accurate) analyses for lower risk, lower consequence problems. For example, almost everyone will perform a TapRooT® investigation when there is a serious injury; this is a high-consequence incident, and preventing it in the future is perceived to have the highest ROI. But what about a near miss? Or maybe someone tripped over an air line on the floor, dropping a repair part and damaging it? Most companies will either not perform any investigation, or they will default to “easy” methods (5-Why’s, etc.). Why spend any time on these “simple” incidents? Let’s just do a quick “analysis” and move on?
While I completely understand this thought process, there are some serious flaws in this thinking.
- Low ROI. While a particular incident may not have caused a large loss, this dos not mean it automatically deserves no attention. Maybe tripping over the air line only caused $800 in damage this time. But what about the other issues that have been caused by poor housekeeping in the past? What if the person had tripped and fallen over the edge of a platform? Making a quick assumption like this can allow you to miss potentially serious issues when taken together. Performing a poor analysis will lead to repeats of the problem.
- Poor results of “quick” RCA methods. Keep in mind that a quick method probably means that you did not gather any information. You are therefore performing an “analysis” without any data to analyze. If your analysis method takes 5 minutes, you have probably just wasted 5 minutes of your time. If you’re going to perform an RCA, make sure it gets to useable and consistent answers.
- TapRooT® is only for the big stuff. This thought often frustrates me. It is true that you will not perform a TapRooT® investigation in 5 minutes. However, any method that purports to give you magic answers in a few minutes is not being honest. See #2 above. However, that does NOT mean that TapRooT® must take days of your time. For simple investigations, the results of a TapRooT® investigation may be found in just an hour or so.
So, how do we use TapRooT® for lower risk or low consequence problems? This year, we have modified the TapRooT® methodology to allow you to use the steps of the process that you need to perform a great investigation on simple problems. This updated process isn’t really new; it just codifies how we’ve taught you to use TapRooT® in the past for these simpler problems. We make the process more efficient and give you the opportunity to optionally skip some of the steps.
Here is the new process flow for low to medium risk incidents:
There are some important points that I wanted to highlight about this new process flow:
- You always start with a SnapCharT®. There is no way to perform any type of analysis unless you first gather some information. Again, any other process that advocates performing an analysis on the information you received in a quick phone call is not a real analysis. The SnapCharT® ensures you have the right information to actually look for root causes.
- There is an off-ramp right at the beginning. Once you’ve gathered information in a SnapCharT®, you can then make an intelligent decision as to whether this problem has the potential to uncover significant problems. You may find, after building your SnapCharT®, that this really was an extremely low potential problem, with minimal consequences. You will then stop the analysis at that point, put simple corrective actions in place to fix what you found, and then document the problem for later trends. That’s it. While most investigations will continue on with the rest of the process, there are some issues that do not require any further analysis and don’t deserve any further resources.
- For most investigations, you will continue by identifying Causal Factors, and run those Causal Factors through the Root Cause Tree®. No different than before.
- For these simpler problems, it probably is not worth the effort of looking for generic causes. We have made this step optional. It you feel the problem has the potential to be more widespread, you can continue to look for generic issues, otherwise, go straight to corrective actions.
- Low to medium risk incidents probably do not need the resources you would normally expend writing full SMARTER corrective actions. We encourage you to write corrective actions based on the guidance in the Corrective Action Helper®, but writing fully SMARTER fixes is probably not necessary.
For more serious incidents, we would still use the full 7-Step TapRooT® Process that you are familiar with. However, for lower risk or lower consequence problems, this abbreviated process flow is much easier to use, allowing you to more quickly work through a TapRooT® investigation. Why use 5-Why’s and get poor results (as expected) just to “save time,” when you can use the simplified TapRooT® process to get MUCH better answers with less effort than before?
The 2-Day TapRooT® Root Cause Analysis Course not covers this simpler method of performing TapRooT® investigations. Attendees will still be able to perform investigations on any incident, but we stress this more efficient process flow.
Choose a course and register here!
Did you know… TapRooT® has a block of rooms at the Westin Riverwalk hotel in San Antonio for attendees to get a discounted rate? Not only is the Westin hotel ideally located on the historic and beautiful Riverwalk, it is also the venue for the 2016 Summit. With these perks plus a discount, why would you not book your room today?
The deadline for booking your room with the TapRooT® room block is July 15. Hurry now before they all fill up!
Click here for all the information you need to book and prepare for your trip to San Antonio.
There is also still time to register for the TapRooT® Summit. Follow the links below to find all the reasons why you need to be in San Antonio for the 2016 Summit.
Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.
One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…
First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.
So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):
• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations
If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.
Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:
A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.
The data for the yearly compliance is presented on a Pareto Chart below.
The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:
Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.
I hate to use clichés, but WORK SMARTER NOT HARDER!
Want to learn more? I have a couple of opportunities that might interest you:
If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on August 1-2.
If you are not there yet and want to learn how to collect data and trend, consider the Advanced Trending Techniques Course, also on August 1-2.
Thanks for taking the time to read the blog, and happy investigating/auditing.
We sometimes take conveyor belts for granted. “Just a motor, some rollers, and a big flexible belt.” But for those of us that use conveyor belts as a critical part of our business, we know how impactful a belt system failure can be. Additionally, a failure can cause more than just an inconvenience; failures in your belt system can lead to overheating and serious fires.
Here are some good ideas to help keep your conveyor belts running smoothly and safely.
A colleague at a recent Rail Safety conference pointed me to this article on how to change people’s behavior on rail lines in London. How do we influence people to:
– put trash in trash bins
– be courteous while playing music
– keep feet off the train seats
They’ve tried signs and warnings. I think we can all agree those have limited effect. There are audible reminders. The escalators in Atlanta Airport talk to you continuously on the way down to the trains.
Here are some other (gentler) ways the London Underground is trying to influence passengers to do what is required.
Upcoming TapRooT® Public Courses:
From Transocean Discoverer Enterprise …
I admit to being an information junkie, and list article headlines steal my attention every single day because they are tasty morsels of knowledge I can’t resist knowing.
10 Things You Didn’t Know About …
15 Things You Need to Know About …
20 Things You Should Consider About …
You get the idea!
Not to say that information is a bad thing ….
but with the Internet we are all on information overload. What happened to simply taking action?
I love this author’s idea about implementing a “deprivation week,” disconnecting from information sources and just doing the work you know you should be doing. If you feel like you are operating less successfully because of an overwhelm of information, check out his advice to quit learning and start doing: 10 Overlooked Truths about Taking Action
TapRooT® will be traveling to Sao Paulo, Brazil June 22 – 26 for a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course. Will you be joining us? Sao Paulo is the most populous and wealthiest city in Brazil. The city is full of cultural, museums, parks, and monuments. It is also a melting pot city, home to Italian, Arab, and Japanese diasporas. This gives visitors an unique experience when visiting Sao Paulo. So stay a couple of days after the course to immerse yourself in what Sao Paulo has to offer.
Vila Das Rosas – Looking for a vegetarian option? Well, look no further. At Vila Das Rosas you can enjoy your meal in a tranquil garden after your long day of shopping.
Savor Sao Paulo: Are you a foodie? Then you definitely want to check out Savor. They offer different types of food tours around Sao Paulo. So sit back, relax, and prepare to get stuffed!
Tche Cafe Bar: Is a great place to go if your looking for friendly staff and live music. The atmosphere is laid back and the drink selection is vast.
Templo Da Carne Marcos Bassi: Try out TripAdvisor’s top rated Brazilian Steakhouse. It is one of the best meat restaurants located in Sao Paulo. Below is a video explaining how they prepare their meat for guest.
Jardim Zoológico: This zoo is situated in the beautiful Parque do Estado. It is Brazil’s biggest zoo that provides shelter for more than 3,000 animal species.
Ibirapuera Park: Your trip to Sao Paulo wouldn’t be complete without visiting this exquisite park. It is home to the Japanese Pavilion, a planetarium, sports arena, an array of museums, and many other attractions.
Sao Paulo Museum of Art: Known locally as MASP, it houses one of Latin America’s most important art collections. You can see famous European artist such as: Degas, Renoir, Bonnard, and many many more!
Below is a video showing you the beautiful sights and the top 7 places you should visit in Sao Paulo, Brazil.
Have you been to Sao Paulo before? What are some of your favorite attractions?
We just want to take a moment to honor those who have served, those who are active military, and the families of our military. Home of the free because of the brave. Thank you for your sacrifice.
Plan your next TapRooT® public course trip to Rome, Italy! Take advantage of our 2-Day Incident Investigation and Root Cause Analysis Course on March 18th in one of Europe’s oldest cities. Rome has been noted as one of the most continuously occupied cities in history keeping their culture growing. The vast amount of knowledge you can learn from their historic sites and our TapRooT® course is well worth the trip.
Pinsere Roma: Fresh, Italian pizza, does it get any better than that?
Gelateria Valentino: Every flavor of homemade Gelato you could imagine. Always a popular spot in Rome.
Volee: Looking for a nicer, gourmet restaurant? Volee is sure to offer an authentic, Italian food experience.
Colosseum: You can’t visit Rome without touring the world-famous Roman Colosseum.
Arcibasilica di San Giovanni in Laterno: Take in thousands of years of art and architecture in one amazing building.
Centro Storico: Take a walk through the shops and see first-hand the authentic Italian culture.
REGISTER TODAY: Follow this link for more information on the course and registration.
SAVE THE DATE for our Global TapRooT® Summit on June 1-5. Register Here.
Thanks to Harry Thorburn for these pictures of a recent onsite course at Lewek Constellation in Norway.
For more information on our Public TapRooT® Courses around the world, click here!
For more information on our Onsite Course options, click here.
Save The Date for our annual Global TapRooT® Summit on June 1-5.
Ever wanted to take a trip to Ireland? TapRooT® will be holding a 2-Day Incident Investigation and Root Cause Analysis public course in Dublin on February 9-10. The scenery and pubs that Ireland is known for are not the only things that hold them apart from everyone else. Dublin was listed as a highly rated global city by the Globalization and World Cities Research Network making it one of the top thirty cities in the world. However it’s modern city growth can never take away the rich history that surrounds the country. Each of the brick streets, castles and stone bridges date back hundreds of years making Dublin quite the well-rounded city. You won’t want to miss this opportunity to travel to Ireland and learn Root Cause Analysis.
Sabor Brazil: A fancier, gourmet style dinner with a taste of Brazil got this restaurant the Tourists Choice Award.
Bad Bobs: Perfect for a night out to eat a relaxing, delicious meal at an official Irish Pub.
The Lotts: Bar quizzes, fun entertainment and award winning food are the best combination for a great time in Dublin.
Irish Whiskey Museum: If you’re in Ireland, you have to learn about the history behind their whiskey and how it became apart of the culture.
Traditional Irish Experience: Let a tour guide take you around to experience the local way of life and see if you’ve got what it takes to be Irish.
Extreme Ireland: This is the single best way to see all the major historical buildings, castles and landmarks along with a knowledgeable tour guide.
Register for the course HERE.
Save the Date for our annual Global TapRooT® Summit coming up in June! Information and Registration here.
Thank you to Jesus Alonso for taking great pictures for us to share. These are from a recent TapRooT® Course in Monterrey, Mexico.
Want more information regarding our TapRooT® Public and Onsite Courses? Click Here.
Interested in joining us at our annual Global TapRooT® Summit in June 2015? Click here for more information.
Have you ever visited Aberdeen, Scotland? Join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training Course on January 26-30, 2015. Aberdeen is known for many things in the northeast such as their busy heliports, oil industry, education and seaport. It was also recognized to be a leading business hub and a “super-city” by the HSBC. Along with their outstanding economy, Aberdeen has beautiful Victorian Era architecture. You won’t regret visiting this wonderful city!
Mamma Mia: This quaint Italian restaurant serves a little bit of everything with delicious coffee and desserts.
Bite Me: Freshly made, gourmet dishes in a small cafe in Scotland. Give it a try!
Sand Dollar Cafe: A seaside bistro that serves some of the best seafood around.
The Gordon Highlanders Museum: This highly reviews history museum is a tourist and local hit. Learn some interesting Scottish and World history.
Aberdeen Maritime Museum: Interested in boats and sailing the seas? Enjoy a visit to this historical and informational museum.
Craigievar Castle: Take a step back in time and visit a real life castle.
REGISTER HERE for this Aberdeen course.
Click here for more information on other international TapRooT® courses.
Today marks the end of yet another great course in Dubai. Here are some pictures of the students and the final team exercise presentations:
Our next set of courses in the Middle East will be in March; a 2 day in Dubai or a 5 day in Doha. To join one of these courses, register HERE
The staff at System Improvements really enjoys working with our customers. One great way to keep in touch with our staff is to connect with them on LinkedIn. You can see what they’re up to, where they are, and read about the great ideas they have for you. It’s also an easy way to contact them if you need assistance or answers to any questions.
We invite you to connect with us! Here’s a list of some of our staff and their LinkedIn contact link:
Mark Paradies (President): www.linkedin.com/in/markparadies
Linda Unger (Vice President): www.linkedin.com/pub/linda-unger/8/950/2a1
Ed Skompski (Vice President): www.linkedin.com/in/edwardskompski
Ken Reed (Partner): www.linkedin.com/in/kenreedprofile
Chris Vallee (Senior Associate): www.linkedin.com/in/christophervallee
Dave Janney (Senior Associate): www.linkedin.com/in/davejanney
Becky Marambio (Sales Associate): www.linkedin.com/in/beckymarambio
Benna Dortch (Sales Associate): www.linkedin.com/in/bennadortch
Michelle Wishoun (Licensing Associate): www.linkedin.com/pub/michelle-wishoun/14/191/b35
Barbara Phillips (Editorial Director): www.linkedin.com/in/barbaracarrphillips
Steve Raycraft (Tech Support): www.linkedin.com/pub/steve-raycraft/37/472/3a2
Cherie Larson (Accounting Director): www.linkedin.com/in/cherielarsontn
Judy Potok (Public Course Planner): www.linkedin.com/in/judypotok
Natalie Tabler (On-site Course Planner): www.linkedin.com/pub/natalie-prendergast-tabler/21/438/691
Thank you to Mhorvan Sherret for sending us some great photos from a recent TapRooT® OnSite Course in Dubai, UAE.
For more information regarding public or onsite TapRooT® courses, click here.