Root Cause Analysis Blog

One of the elements of the revised standard that I thought would interest readers of this blog is  LD.4.260. It states that:

The organization implements an integrated resident safety program throughout the organization.

LD.4.260 includes 13 specific elements:

1. There is an organization-wide, integrated resident safety program.

2. One or more qualified individuals or an interdisciplinary group manages the organization-wide safety program.

3. The scope of the program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events, which have serious adverse outcomes.

4. All departments, programs, and services within the organization participate in the safety program.

5. The organization creates procedures for responding to system or process failures, such as continuing  to provide care, treatment, and services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.

6. The organization: Defines responses to various types of potential adverse events. 

7. The organization: Conducts proactive risk assessments.

8. The organization: Makes support systems6 available for staff members who have been involved in a sentinel event.

9. The organization: Analyzes and uses information about a system or process failure to improve safety.

10. The organization: Provides systems for the internal and external reporting of a system or process failure.

11. The organization: Provides governance at least once a year, with written reports on all system or process failures, on the number and type of sentinel events, on whether the residents and the families were informed of the adverse events, and on all actions taken to improve safety, both proactively and in response to actual occurrences.

12.  The organization: Disseminates lessons learned from root cause analyses to staff who provide services or are affected by the situation.

13. The organization: Encourages external reporting of significant adverse events, including voluntary reporting programs in addition to mandatory programs.
To review the revised program see:

http://www.jointcommission.org/NR/rdonlyres/CD9A619C-C364-4543-A840-50E9AD914E17/0/09_ld_ltc2_prepubstds.pdf

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The Superior Daily Telgram reports thyat 4 workers were overcome by Hydrogen Sulfide in a confined space at the Lakehead Blacktop Material Landfill. federal OSHA will be conducting an investigation. For complete details see:

http://www.superiortelegram.com/articles/rss.cfm?id=23269&freebie_check&CFID=64903453&CFTOKEN=97764091&jsessionid=88306f07ed346e6f3d44

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Agence French-Presse reports that the cause of a ship going aground on a Greek reef was an inaccurate chart that was issued by the Greek Hydrographic Service. The cruise company says that the reef was larger and further out to sea than the chart indicated.

Is this the result of an accident being caused by a single failed Safeguard (the chart) or should have other Safeguards been in place?

For more information see:

http://newsinfo.inquirer.net/breakingnews/world/view_article.php?article_id=98459

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Human Factors Series 1: Taking Signal Detection Theory (SDT) out of the Laboratory and into the Workplace

Everyday we have to make decisions about uncertain events. Signal Detection Theory is a model of how people make uncertain decisions. To put it simply, can you single out one object (beep, light, defect…) from the surrounding workspace? How important is it not to miss the object you are searching for (correct hit) and how detrimental to you is it if you indicate the object is there when it isn’t (false alarm)? What does senior leadership reward?

An article published in http://www.latimes.com/ stated that 75% of the fake bombs and explosives sent through LAX Airport security screeners during an undercover terrorism drill passed through undetected.

Airport authorities were not surprised. The simulated devices were not “sticks of dynamite” but “more like caps on a pen….a piece of metal with a wire in it. TSA’s remedy is to send poorly performing screeners into remedial training until their screening scores get better or remove the employee. To see Signal Detection Theory used to assist training for security screens see this SDT Simulation.

A former security director at LAX cited in the article stated that authorities could: purchase more advanced screening equipment, fund the proper number of screeners at each airport and ensure that screeners who consistently fail covert tests are removed.

The question I ask is how does one get from the incident of missing the explosives in the screening process to corrective actions such as remedial training, possible firing, hiring more employees, and purchasing better equipment? This is where the human factors science such as Signal Detection Theory behind TapRooT® could have helped with the root cause analysis.

Use a structured root cause analysis like TapRooT® that asks questions tied to human engineering such as were errors (targets) detectable? Are choices made by the person subject to knowledge-based decisions? Are the safeguards or barriers dependent on human action?

While types of human error are subject to change, human factors science continues to be introduced into the workplace with increasing usability. Replacing “common sense” with a structured root cause analysis based on science will continue to improve corrective actions.

Human Factors Series 2 will discuss Management Systems influence on correct hits and false alarms.

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The Associated Press reported that 14 railway officials, including the Deputy Chairman of the Railways Authority, were sentenced to one year in jail for their part in a 2006 train accident that killed 58 people. At least part of the cause of the accident was reported to be poorly maintained switching equipment.

Below is a sample of Mid-East TV coverage from the accident (some graphic accident footage included) from the web.

QuickTime Format (.mov)

QuickTime Format (.mov)

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