Root Cause Analysis Blog

 

When is a leak in a nuclear reactor minor?

Posted: September 20th, 2018 in Current Events, Equipment/Equifactor®, Pictures

NewImage

I saw an interesting article in the Military News yesterday. The headline read:

Navy: ‘Minor’ moisture leak in nuclear plant prompts sub’s return to Groton base

This caused me to think of several things…

First, if a ship has to return to port, the leakage was not minor.

Second, I’m glad they returned to port for repairs. Much better than having the leak progress into an accident.

Third, why did we hear about this?

The article doesn’t give many details about the problem and the Navy spokesperson downplayed the significance by calling coming back into port for a leak:

…not uncommon, and ensures the ship is maintained at a high state of readiness.

I guess I was in the Navy a long time ago when things like that were uncommon.

In fact, back then if something like this happened, there would not have been a press release. The ship would have gone ito port, been fixed, and gone back out to sea.

Los Angeles class subs are getting old (USS Pittsburgh is over 30 years old) and I hope the Nuclear Navy really is maintaining the high state of readiness that they are known for.

How is your maintenance program? Need help troubleshooting equipment problems? Consider having an TapRooT®/Equifactor® Course at your site. Contact us by clicking here.

5 Cognitive Biases that Influence Incident Investigations

Posted: September 20th, 2018 in Investigations, Root Cause Analysis Tips

Whether we admit it or not, we are constantly under the influence of cognitive biases that distort our thinking, influence our beliefs, and sway the judgments we make as investigators.

Most of us are familiar with confirmation bias (looking for evidence to support a hypothesis, and rejecting any evidence that does not). However, did you know there are over 250 cognitive biases?

Here are five that may be affecting your investigations:

  1. Overconfidence. Yes, overconfidence is a bias even though it doesn’t sound like a fancy psychological term. This can really be a problem with experienced investigators because they know more, and may be more convinced that they are right.
  2. Stereotyping. Expecting a group or person to have certain qualities without having real information about the person. Again, a term that we are familiar with but may not realize we are doing to those involved in incidents. I’m not just referring to gender or racial stereotypes. You can stereotype a person many different ways. Here are some other examples: “She has an MBA. She must be smart.” “He has 20 years in the industry, he must be experienced.”
  3. Choice-supportive bias. When you decide something you tend to feel more attached to your decision, even if the decision has flaws.
  4. Bandwagon effect. Not sure of what to think of an investigation? Take the easy road . . . jump on the bandwagon. The probability of one investigator adopting a belief increases based on the number of team members who hold the same belief.
  5. Blind-spot bias. This simply means that we don’t accept that we could possibly be biased! We tend to notice biases in other people and not within us. We all fall into biases and need to be aware of that.

How do you avoid biases in an investigation? Use a system that doesn’t start with a hypothesis, TapRooT® Root Cause Analysis. Using the guided system, an investigator does not:

  • rely on his/her limited knowledge (no one can possibly know everything!).
  • fit workers into stereotypes that align with our hypothesis.
  • become married to his/her ideas.
  • become easily influenced by others.
  • have to fight his or her biases!

You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions. Once you understand what happened and identify the mistakes, errors or equipment failures, you will then be ready to analyze why the safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary. This system gets you to think beyond your current knowledge, and decreases investigator bias.

Learn the entire TapRooT® System in just two days. View the upcoming schedule here.

 

TapRooT® Software Academy: Introduction To the TapRooT® Software

Posted: September 20th, 2018 in Uncategorized

TapRooT® is excited to present a new video series called “Software Academy.” Once a month we are uploading helpful videos that highlight our software features and answer some of our frequently asked questions. Today’s video will be a simple introduction into our software.

If you enjoy this video don’t forget to follow us on social media to stay up to date on video releases (social links are listed below).

If you cannot view the video, please CLICK HERE

 

Did you find this video helpful? If so please leave a comment below and tell us what type of video you would like to see next.

Interested in learning more about our software or maybe you need a fresher course? If so, click on the links below to see what public courses are available near you.

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

 

You can follow us on:

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How far away is death?

Posted: September 20th, 2018 in Accidents, How Far Away Is Death?, Video

Have respect for the anchor!

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

Posted: September 19th, 2018 in Career Development Tips, Investigations, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, Topic of the Week

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Chris Vallee discussing, Do you perform incident investigations like you watch the news?

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort. You don’t want to miss a minute of the TapRooT® Summit!

How Could the Best Process Safety Advice Come from the 1960s/1970s?

Posted: September 19th, 2018 in Performance Improvement, Pictures

RickoverS1W

There are many “experts” in process safety. Their advice has become laws in the USA and Europe. But accidents continue. Why?

Perhaps we should go back to the real expert on process safety – Admiral Rickover.

What did he have to say about process safety (or as he put it, reactor safety)? What are we missing in our current efforts to improve process safety? See this set of articles about normalization of deviation and learn what the expert – Admiral Rickover – had to say about process safety:

http://www.taproot.com/archives/54027

 Then read his semi-official biography:

Rickover: The struggle for Excellnce

Screen Shot 2018 08 02 at 3 41 10 PM

Click on the book above to purchase it on Amazon.

TapRooT® Around the World: Denver

Posted: September 18th, 2018 in Courses, Pictures, Training

Thanks to Marcus Miller for sending in this course photo from Denver! It’s not too late to get into the picture and advance your career!

Are you interested in attending a TapRooT® Training Course? Click on the links below to view our upcoming courses to a city near you.

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

TapRooT® Around the World: Cork, Ireland

Posted: September 18th, 2018 in Career Development, Courses, Human Performance, Meet Our Staff, Performance Improvement, Pictures, TapRooT® Instructor, Training

Look into the Two-Day TapRooT® Techniques course in Cork, Ireland, where students and TapRooT® Instructors Thomas Di Giacomo and Chris Vallee gathered at the Imperial Hotel Cork on South Mall. Attendees enjoyed a bit of history along with the TapRooT® course, as guests such as Sir Walter Scott, William Thackeray, Franz Liszt, and Charles Dickens have stayed at the hotel.

In the span of the two-day course, students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Upon course completion, attendees received a certificate and a 90-day subscription to TapRooT® VI, the online software service.

Many thanks to Tom and Chris for capturing and sharing these great pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

Posted: September 18th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, Topic of the Week, Video

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What does a bad day look like?

Posted: September 18th, 2018 in Bad day, Pictures

Because signage matters, right?

Monday Accident & Lessons Learned: Fatal Ammonia Accident

Posted: September 17th, 2018 in Accidents, Investigations, Video

What were the Causal Factors? 

Leave your comments here…

Career Opportunities for Candidates with TapRooT® Skills

Posted: September 17th, 2018 in Career Development, Courses, Job Postings, Performance Improvement, Training

You’re telling everyone that you’re an effective problem-solver when you have the expertise of TapRooT® training on your resume. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to everyone you meet, especially prospective employers. If you have TapRooT® training and skills, explore your professional advancement through these global opportunities.

Technical Manager

Regional H&S Advisor

Manager, Health, Safety, & Environment

Safety Technician

Project Planner

Commissioning Engineer

Lab Quality Technician

Environmental Safety & Health Manager 

Quality Inspector

Quality, Health, Safety, & Environmental Manager

Project Manager

Process Safety Advisor

HSE Manager

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through one of these TapRooT® courses to advance your professional development and your career.

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Weekly Wisdom

Posted: September 17th, 2018 in Career Development, Wisdom Quote

Investigative Interviewing Webinar: Tips for collecting better quality and quantity of evidence

Posted: September 14th, 2018 in evidence collection, Investigations, Root Cause Analysis Tips

TapRooT® Instructor, Barb Carr, was a recent guest expert for Intelex, a global leader in EHSQ software. View the recorded webinar to learn how to become a more effective interviewer, and collect better quality and quantity of evidence.


Friday Joke

Posted: September 14th, 2018 in Jokes

Technically Speaking – User Settings

Posted: September 13th, 2018 in Software, Technical Support, Technically Speaking

This week in Technically Speaking we will be going over user settings in TapRooT® VI. View the PDF below and get to know your way around the software better!

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: Johannesburg, South Africa

Posted: September 13th, 2018 in Career Development, Courses, Human Performance, Meet Our Staff, Performance Improvement, Pictures, TapRooT® Instructor, Training

Take a look into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, taught by TapRooT® Instructor Sanjay Gandhi. We are grateful to Sanjay for sharing these pictures that show teamwork, the TapRooT® learning experience, and a great time in the process!

Through TapRooT® Training with our exceptional instructors, students learn to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Is It Better To Be Fast or Good?

Posted: September 12th, 2018 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT

Imagine the old west. Two gunslingers standing 20 yards apart. It’s time to draw.

NewImage

Would it be better to be fast or good? As Wyatt Earp said:

Fast is fine. Accurate is final.

What does this have to do with root cause analysis?

I had someone ask me the other day:

How long should a simple root cause analysis take?

If you use Spin-A-Cause™, the answer is about 5 seconds.

Spin A Cause

But you have to answer the question …

Do you want FAST or GOOD?

But what if you could have BOTH?

That’s what the 2-Day TapRooT® Root Cause Analysis Training and the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about. Fast and Good simple investigations.

We selected the minimum number of powerful root cause analysis tools and built a simple process to perform simple investigations fast and accurately.

How long does it take to apply these techniques? Maybe 30 minutes to an hour once you have the information you need to answer the questions. Maybe slightly longer. Maybe longer yet if the incident turns out not to be “simple.”

The biggest variable is collecting the information (evidence). The second biggest variable is the requirements of your investigation system (presentations to management and approval red tape).

So if you are ready to be fast and good, sign up for one of our public 2-Day TapRooT® Root Cause Analysis Courses today. Here are the upcoming dates and locations:

http://www.taproot.com/store/2-Day-Courses/

Or have a course at your site. Contact us for a quote by clicking HERE.

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

Posted: September 12th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Topic of the Week, Video

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professional Michelle Wishoun who will discuss TapRooT® Certified Instructors. You’ll also learn more about our upcoming Global TapRooT® Summit during today’s session.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 12

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort. You don’t want to miss a minute of the TapRooT® Summit!

The UK General Medical Council Shows a Lack of Understanding of Root Cause Analysis

Posted: September 11th, 2018 in Accidents, Current Events, Human Performance, Investigations, Medical/Healthcare, Performance Improvement, Root Cause Analysis Tips

Screen Shot 2018 09 07 at 6 10 40 PM

Here is a quote from an article in gponline.com:

“The GMC says human factors refers to the ‘environmental, organisational and job factors –
and human and individual characteristics – which influence behaviour at work in a way
that can affect health and safety,’ while root cause analysis is a systematic process for identifying
‘root causes’ of problems or events and an approach for responding to them.

Responding to the review, the GMC said: ‘Focusing on root cause analysis may not always be
the best way of dealing with all investigations and we understand that exploration of a
human factors approach is underway at several NHS Trusts in England.'”

To use an “English” term …

“What rubbish!”

Who gave this team of senior managers the idea that human factors is not a part of a root cause analysis?

If they aren’t including human factors, behavior, organizational factors (Management Systems), procedures, training, communications, work direction, and quality processes in their root cause analysis … THEY AREN’T DOING ROOT CAUSE ANALYSIS THE RIGHT WAY.

Instead of trying “human factors,” they should try a root cause analysis system that automatically includes “human factors,” the TapRooT® Root Cause Analysis System.

Find out more about how TapRooT® includes human factors at:

http://www.taproot.com/products-services/about-taproot

Why did they decide they needed to change? Because their system exhibits a blame culture and abysmal root cause analysis. A particle case involving Dr. Bawa-Garba finally got senior leadership to admit that they need to improve. But instead of finding out what is wrong with their practices, they decided they needed a new buzz-word … human factors.

We have written several articles about root cause analysis practices in the UK and the need for improvement (see Dr. Death, Healthcare Scandal, Bias & Blame, House of Commons Calls for RCA Training, Highest Number of Serious Incidents. and Not Preventable), but even though a decade has passed, little improvement has occurred.

Will a new focus on human factors solve the problems of the UK National Health System? Doubtful. Good root cause analysis (that includes human factors among other things), and implementation of appropriate corrective actions could have solved these problems years ago. I would guess that:

  • poor root cause analysis,
  • unwillingness to change,
  • understaffing and budgeting,
  • poor Management Systems, and
  • bureaucracy,

will continue to haunt NHS patients no matter how many human factors courses are given to hospital staff members.

NHS senior leadership must understand what is wrong (through advanced root cause analysis) and be willing to make change happen BEFORE real improvement will occur.

Contact us (CLICK HERE) if you are committed to making root cause analysis (that includes human factors) work at your facility or company.

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

Posted: September 11th, 2018 in Career Development Tips, Meet Our Staff, Topic of the Week, Video

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 12

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What does a bad day look like?

Posted: September 11th, 2018 in Accidents, Bad day, Great Human Factors, Pictures

Because who doesn’t want to take a trip in their hot tub?

TapRooT® launches a new edition of the Friends & Experts eNewsletter focused for Healthcare

Posted: September 10th, 2018 in Media Room, Medical/Healthcare

Great news for our healthcare readers!  TapRooT® is making a commitment to the healthcare industry by creating healthcare’s own TapRooT® E-Newsletter and here is why:

A recent Johns Hopkins study claims more than 250,000 people in the U.S. die every year from medical errors. Other reports claim the numbers to be as high as 440,000. Medical errors are the third-leading cause of death after heart disease and cancer (Makary & Daniel, 2016).  The cost of sentinel events in time, money and reputation is significant especially when good margins measure only in the single digits.  The Society of Actuaries estimated that medical errors cost the U.S. $19.5 billion in 2008, with non-reimbursable medical costs per error ranging from $810 to $47,099 (Milliman, 2010). Total costs, which include in-hospital mortality and short-term disability costs, reached over $93,000 per error.

This begs the question; how do health care organizations reduce the risk and financial burden of mistakes and errors that cause poor clinical and financial outcomes?

I whole-heartily believe that the healthcare industry can learn from the likes of oil and gas, mining, nuclear and utilities industries. TapRooT’s® clients typically operate their business’s in dangerous industries. Quite literally lives depend on TapRooT’s® world class investigation, root cause analysis and corrective action implementation processes.  Our clients are the top tier companies in these industry sectors: household names such as Chevron, Exxon, DuPont, Delta, Siemens, and Nuclear Fuel Services.  These enterprises fully understand just how critical safety and quality are and how they impact their organization’s reputation and bottom line.  Our clients clearly see the value of a very well thought out and pragmatic approach to developing a formal root cause analysis platform within their organization.

My goal is simple, to introduce TapRooT® to health care organizations so they can also realize and benefit from the value of such a program and platform.  The healthcare newsletter will be one strategy to meet that goal.  Our content will focus on bringing information to our readers about programs such as CMS’ Value Based payment models which attempt to tie reimbursement to financial and performance accountability.  It will also bring insightful resources to our readers’ attention like the must-read book for all health care supervisors and executives:  Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety (The Culture and Politics of Health Care Work).  Here is an excerpt from the book and a link to a video that highlights the value of this book:

“In medicine it seems now to be universally acknowledged that failures of teamwork and communication-not simply failures in technical proficiency-cause the majority of medical errors and injuries in hospitals and other health care facilities. Studies too numerous to cite have documented that it is not the incompetent surgeon or a small group of bad apples in other disciplines that cause harm to patients. It is human factors – the failure of human beings to relate effectively and productively with one another highly technological settings, to recognize human limitations in performance ability owning to “Life factors” such as extreme fatigue and emotional distress, and to actively resist the culture of blame- that are the major cause of patient harm.” p. 8.

https://youtu.be/L_oXvXtQlBA

TapRooT® has 30 years of research and experience which we will bring to our readers.  TapRooT® exists to solve problems like worker comp issues, quality issues, environmental releases, or god forbid, fatalities and injuries through training on investigations techniques, using the evidence to find causal factors for effective root cause analysis and the implementation of corrective actions that can be both validated and verified so those problems are solved for good.

When you find yourself frustrated that your organization’s corrective action are mostly re-training, re-writing policy and procedures, disciplinary actions like write ups and termination and decide you’d like to spend just a little time having a conversation about the problems you are experiencing and possible solutions, my email is marcus.miller@taproot.com.  We can set up a time to talk about your problems and see if it makes sense to take the next step with an introduction to TapRooT®.

It is our privilege to provide this monthly newsletter to our healthcare subscribers so please enjoy the first edition on September 11. If you’re not subscribed, contact editor@taproot.com to sign up.

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Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

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Per OhstromPer Ohstrom

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Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

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Wayne BrownWayne Brown

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