Root Cause Analysis Blog

(link to pictures with major findings highlighted)

If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.

It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?

A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.

My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.

Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.

For details, see:

http://www.nukeworker.com/job/view.php?job_id=6700

Why do articles about medical errors have an erie similarity?

The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

See:

http://skorcareer.com.my/jobs/engineer-mmc-utilities/engineering/2008/05/

The Air Force Link reports that Col. Richard Haddan will chair an investigation board looking into a recent crash of a T-38 training jet. The crash killed Maj. Brad Funk and his student, 2nd Lt. Alec Littler.

No other information will be released prior to the completion of the board’s investigation.