Root Cause Analysis Blog

 

Upcoming TapRooT® Root Cause Analysis Course in Aberdeen, Scotland – May 22

Posted: March 24th, 2017 in Courses

We’re excited to announce our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, Aberdeen, Scotland, May 22 – 26, 2017.

We know you will appreciate our NEW course materials including new books, updated training and cloud-based software.

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Learn essential to advanced TapRooT® Techniques
and how to use the TapRooT® Software.

 

TapRooT® is not just a root cause analysis system but is a complete investigation process that helps investigators collect the information they need to find root causes.

You’ll love our exclusive software to streamline and organize your investigations for powerful results.  Advance your career and make your life easier with full advanced human performance and equipment troubleshooting technology at your fingertips.

If you want to find the real reason an incident happened, take this course.  
If you want better corrective actions, take this course. ~ C. Hockenbury

Upon completion of the course, attendees will receive a certificate of completion and a 90-Day Subscription to TapRooT® VI, the online software service.

CLICK HERE to register today!

Friday Joke: You’re next

Posted: March 24th, 2017 in Jokes

Joke 2

Technically Speaking – The TapRooT® VI Non-Technical Review

Posted: March 23rd, 2017 in Software, Technical Support, Technically Speaking

brochure computer

When we hear the word software, we all think of CDs that you have to install onto your computer, right? And whenever there is a new update or version, you buy more CDs. And if you run into problems installing (which we all probably do because, if you’re like me, you just click “yes” to every prompt it gives you to make it go quicker), then you just hand it over to the IT Department and hope you didn’t break the entire device. All of us non-tech savvy people have been there. It’s not fun.

But one thing everyone can use, yes, even us technically inept people, is the World Wide Web, the internet, cyberland. The cool thing about the internet is that you don’t have to know everything about HOW it works, you just have to know how to USE it. And thankfully it is quite user-friendly.

Well, TapRooT® decided that our robust root cause analysis software should be accessible and convenient while also fully secure and effective. So what did we do? We redesigned, re-invented, re-created TapRooT® as a solely web-based software.

What does this mean?

  1. Automatic updates: Since it’s all online, our TapRooT® Support team launches all version updates automatically so they are available for you to use immediately without lifting a finger. No more CD’s!
  2. Any device, Any browser: No longer are the days of PC vs. Mac compatibility or strictly desktop computers. Login to your TapRooT® VI online account via any device (PC, Mac, tablet, smartphone, etc.) using any browser (Chrome, Firefox, Safari, Internet Explorer, etc.).
  3. So easy a caveman can do it: If you have questions or concerns regarding your TapRooT® VI account, don’t worry about involving your busy IT Department. Just contact TapRooT® Support and they can walk you through any problem easily and conveniently.

So, what are you waiting for? Step into the World Wide Web and make your life a little easier and your investigations that much better.

Already a TapRooT® user, but still using TapRooT® version 5? Upgrade to TapRooT® VI today!

Interested in implementing the TapRooT® process and using our software? Register for a course to learn all you need to know AND get a 90-day free trial subscription to TapRooT® VI.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

TapRooT® Around the World: Nashville, Tennessee

Posted: March 20th, 2017 in Courses

Dan Verlinde, Angie Comer and I enjoyed meeting and working with course attendees in Nashville, Tennessee last week.  They were dedicated professionals and a great group of humans!

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What’s Wrong with this Data?

Posted: March 20th, 2017 in Accidents, Current Events, Medical/Healthcare, Performance Improvement, Quality, Uncategorized

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):

Summary Event Data

 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.

Calling all Auditors! NEW TapRooT® for Audits Course

Posted: March 17th, 2017 in Courses

We’ve scheduled our new course specifically designed for auditors on May 4-5 in Charlotte, NC.

We have always taught auditing in our courses but we wanted a course that auditors could attend to learn the Essential TapRooT® techniques.

All attendees get a copy of the newly released book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement as well as a Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper®.

Audits Kit

I hope to see you there! For more information and to register, please go HERE

Case Study: Using Dye Packs to Locate Leaks

Posted: March 16th, 2017 in Summit Videos, TapRooT, Video, Video Depot

Watch as Brian Tink discusses how his company used dye packs to help them isolate the location of a pipe leak.

Technically Speaking – Helpdesk Humor

Posted: March 16th, 2017 in Software, Technical Support, Technically Speaking


Do you think that there is an issue of misunderstood verbal communication after watching the above conversation? While the internet won’t break, this is an example of misunderstood communication and how it has the potential to wreak havoc on your company if not identified.

TapRooT® can help you identify these times when verbal communication has been misunderstood and help prevent future incidents.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Time for Another Caption Contest!

Posted: March 14th, 2017 in Contest

Caption this image and you could be the lucky winner!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by April 14.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter.

Our staff will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on April 14.

Get creative and have fun!

via GIPHY

TapRooT® Training in Dallas

Posted: March 13th, 2017 in Courses, Pictures

Another successful TapRooT® training course in the books! IMG_1077

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A Webinar to Optimize Your TapRooT® VI Software Skills

Posted: March 13th, 2017 in Software, Technical Support, Training
If you have been trained in TapRooT®, and want to optimize your investigations, join us. Every month we will be offering a software-specific webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software.
Get the most out of your investment.

What you need to know: 

  • When: Webinar Wednesdays occur the fourth Wednesday of every month
  • Time: 2:00-3:30pm Eastern Time
  • Length: 90 minutes
  • Price: $195 per seat
  • Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.

HERE IS A COMPLETE LIST OF UPCOMING WEBINARS

THE NEXT ONE IS MARCH 22, 2017

Friday Joke: Oops!

Posted: March 10th, 2017 in Jokes

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Credit: Cartoon Impact

Technically Speaking – TapRooT® VI Notifications Feature

Posted: March 9th, 2017 in Software, Technical Support, Technically Speaking, Video, Video Depot

Here is a quick video highlighting the new notifications system in TapRooT® VI.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, it doesn’t mean it has to be complicated!

Evidence Collection and Root Cause Analysis by Accident? On your mark, get set… STOP!!

Posted: March 8th, 2017 in Root Cause Analysis Tips

Now What
 

“Don’t collect evidence by accident!”

A phrase that I repeat often while teaching our TapRooT® Root Cause Analysis Method, along with…

Go Out And Look (GOAL)

I know, the phrases above may look like another safety/quality slogan of the day but are they? Maybe they should be the simplest guidance to increase the probability of not losing relative facts after an industrial injury, facility/property damage, environmental release, product defect, customer complaint or near miss/hit to any of the above.

Here is a list of issues that occur by not following the concise instructions above:

  • Lost/Missing evidence
  • Evidence spoliation (whether intended or not)
  • Guessing driven by assumptions tied to past problems
  • Regulatory Write Up for delayed incident reporting (extent and magnitude of problem not understand in time by not Going Out And Looking)

Why would any established industry, often overseen by a regulatory agency, have to worry about collecting evidence by accident or GOAL? Don’t many companies have procedures and work instructions on how to manage an industrial accident or regulatory write up? The latter question is where the problem resides. Actually, it starts before a major incident occurs.

Companies are good in many cases at handling major accidents and their evidence collection. What often drives what gets looked at is the company’s Incident Matrix. The matrix in many cases stops employees from Going Out And Looking and encourages last minute evidence collection by accident. Below is a typical matrix.

Vallee

If the employee has “7 days?” or “as soon as practical”, what does that do to evidence collection delays or GOAL? What does that do to how the employee collects evidence and how the root cause analysis is performed? If the “big problems” have an investigation protocol, do the employees use the same protocol for the unsafe practice issues?

The process you create to manage investigation resources can hurt if not managed correctly.

For more thoughts on collecting evidence and the impact to the business based on your company’s own protocols, read the following….

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

You are just one Causal Factor from your next major Incident. Can you prevent it?

How Fast Can You Do A Root Cause Analysis (1 hour, 1 day, 1 week, 1 month)?

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

3 Reasons a SnapCharT® is Essential to Evidence Collection

Starting Your Investigations: The Power of the SnapCharT®

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