Root Cause Analysis Blog

See:

http://www.hirediversity.com/jobseekers/jobs/view.asp?ID=2517750

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See:

https://jobs-bannerhealth.icims.com/jobs/62970/job?sn=Indeed

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See:

http://www.oprah.com/dated/oprahshow/oprahshow-20090219-dennis-quaid

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The $25,000 per violation fine is intended to make hospitals improve performance.

13 hospitals were fined. One was fined twice. For more information see the LA Times article:

http://www.latimes.com/features/health/la-me-hospital-fines21-2009may21,0,1715565.story

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Here is the story:

http://news.yahoo.com/s/ap/20090520/ap_on_re_au_an/as_australia_saved_by_drill

Amazing!

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Here’s what Marion Christiansen had to say about the 2008 TapRooT® Summit:

(click to play - WMV format)

Are you planning to attend in 2009 in Nashville, TN (October 7-9)?

If you need to:

- improve patient safety

- enhance industrial safety

- stop human errors

- improve equipment reliability

- improve your root cause analysis

- benchmark performance and learn new best practices

- be inspired and motivated to continue your improvement efforts

You should be there!

Previous Summit attendees say they learned about those topics after attending past Summits. And this Summit will be better than ever.

Plus, this Summit comes with a money-back guarantee!

Attend the Summit. Go back to work and apply what you’ve learned. If you don’t get at least a 10 times return on your Summit fee investment, just send back your Summit materials and we will provide a full refund of the Summit fee.

See why past attendees have so many nice things to say and why many have returned year-after-year. See:

http://www.taproot.com/summit.php

And register for the Summit at:

https://taproot.com/summit.php?t=register

But don’t wait! There’s a reward (an iPod prize drawing) for those that register early. See:

http://www.taproot.com/wordpress/2009/05/12/who-else-wants-a-free-ipod/

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Interesting article about healthcare management and pressure on physicians not to complain. See:

http://www.theage.com.au/national/hospital-juggled-wait-lists-says-surgeon-20090518-bcr0.html

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TapRooT® Summit attendees value our industry-specific best practice sharing sessions not only for the opportunity to learn best practices but also for the networking. Peer networking at the Summit, both socially (at our Reception) and professionally (in the best practice sessions) give attendees twice the opportunity to make long-lasting professional contacts. With all the demands on your time made by your professional and personal life, it’s good to know the Summit is also designed so you will have plenty of time to meet new people.

Networking is just the icing on the cake. Best practice sharing will help you solve many problems you deal with on a day-to-day basis. How is TapRooT® being utilized to promote best practices within the healthcare industry? How are root causes being tracked to evaluate effectiveness of investigations and corrective actions? Come prepared to discuss these and other issues as we seek to promote operational excellence in the healthcare industry.

Harry Wetz and Ed Skompski will be co-facilitators in the Healthcare Performance Improvement Best Practice Sharing session at the 2009 Summit.

Harry Wetz is the Patient Safety Officer and Director of Quality Management of INTEGRIS Health, Oklahoma City, Oklahoma. He is also the Chairman and member of the Board of Directors of INTEGRIS Federal Credit Union. He was a Fellow of Patient Safety Leadership/Fellowship at the American Hospital Association Health Forum. He has served as Chairman and member of the Respiratory Care Licensure Committee at Oklahoma State Board of Medical Licensure and Supervision, and as President of the Oklahoma Society for Repiratory Care. Harry is a graduate of the Respiratory Care Program at Rose State College.

LEARN MORE about the Eliminating Hospital Sentinel Events Track at the 2009 Summit here.

And register early! (And don’t forget registering early means more chances to win great prizes!)

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A Pakistan web site reported that an Australian scientist/virologist has hypothesized that the Swine Flu may have been accidentally produced in a lab while trying to make a flu vaccine for pigs.

Here’s the story:

http://www.sindhtoday.net/world/96367.htm

If this proves to be true … Who will do the root cause analysis?

After reading a story yesterday about people setting up unsupervised home gene splicing labs, the whole deadly virus produced by accident scenario can really get spooky.

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Here is the story:

http://news.yahoo.com/s/ap/20090513/ap_on_fe_st/odd_wrong_side_surgery

Rarely does something like this make the national news, but it happens more than you might think.  Why?  Doctors and Nurses are human, and they make mistakes the same ways and for the same reasons as machinists, factory workers, forklift drivers, pilots, you, and me.  The question is, does the organization have the management systems and best practices in place to stop or minimize human error?  Does the organization apply the knowledge they have effectively or do they seek outside knowledge to help them?  

I’ve asked these questions for a reason; because human performance, best practices, and using knowledge are what the TapRooT® system is all about. Humans only work within the system we (management) provide and we owe it to them to develop and implement a system that works and to fix problems when we find them (or they find us!)

Attend a TapRooT® course today - here is the schedule:

http://www.taproot.com/courses.php

By the way, if you are reading this and are a Healthcare professional, you should join us for the Eliminating Hospital Sentinel Events track at the 2009 TapRooT® summit on October 7-9.  In addition to the summit, we have a two day pre-summit course TapRooT® and FMEA for Your Healthcare Root Cause Analysis.

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Dr. Daniel Ubani (above) made a mistake. No doubt about it, he injected a patient with a fatal dose of a pain killer while making a house call. (Yes - they still do these in the UK.) David Gray, pictured below, died from the error.

Dr. Ubani was NOT intentionally trying to kill the patient (this wasn’t a premeditated homicide).

What do we do next?

Criminal prosecution!

Will this improve the system? You tell me…

The UK Guardian reported on the sentinel event. Read about the political response here:

http://www.guardian.co.uk/society/2009/may/04/german-doctor-overdose-david-gray

There’s more information in this article:

http://www.guardian.co.uk/society/2009/may/04/german-doctor-patient-overdose

Read the Doctor’s apology letter to the family here:

http://www.guardian.co.uk/society/2009/may/04/letter-ubani-doctor-dose-apology

Hear the radio story here:

http://www.guardian.co.uk/society/audio/2009/may/04/foreign-doctor-patient-overdose

One year later, I’m not sure there’s been action to fix “the system.” One person interviewed did say that they had removed the 100 mg bottles of diamorphine from the bags that doctors carry on house calls.

But have they addressed fatigue? The language issues? Doctor qualifications? What about the reasons why the patient hadn’t been treated for the kidney stones so that he wasn’t in pain (and didn’t require a house call)? No mention is made of any of these issues.

Instead, they are arguing about whether a criminal prosecution in Germany is adequate or if the Doctor should have been prosecuted in the UK.

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The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report has an interesting statistic. On average, 52% of hospital staff surveyed did not report any medical errors in their hospital over a 12-month period. The statistic is based on data from nearly 200,000 hospital staff from 622 hospitals nationwide.

Can an employee really go a year without making any mistakes? Very doubtful. Even with outstanding human performance on an well designed action, a person will make a mistake one in 10,000 tries. More normal performance is one error in 1000 tries.

So what do these stats mean? That errors are largely under-reported.

Before you criticize the medical industry, look at your facility’s statistics. How many error reports did you have last year. How many employees do you have. I’d bet that more than 50% of your employees never report a single error.

Have you ever thought about the costs associated with these unreported, uncorrected errors? It many be more than you think. The problem with under-reporting is that cheap opportunities to improve performance (near-misses) are being missed. Only big errors (to obvious not to be reported) are acted upon. So you have to think not only of the cost of the small errors, but of the cost of the big problems that could have been prevented.

Would you like to improve your near-miss reporting? Then there’s a session by Kevin McManus at the TapRooT® Summit that you need to attend:

Learn why people don’t report problems and practical things that you can do to improve your error reporting program to make it world-class.

For complete Summit info, see:

http://www.taproot.com/summit

And if you would like to learn how to analyze and prevent human errors, attend the Stopping Human Error Course before the TapRooT® Summit on October 5-6. This course is being completely redesigned for 2009 (more about this in later posts) but we know that you will learn practical ways to make major improvements in human performance at your facility. I’ll send you the latest details if you e-mail me by clicking on the “Contact Us” button at the top of the page.

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http://arbita.jobhost.org/viewjob.php?id=542579

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Next time you are busy justifying your accident prevention and root cause analysis efforts by concentrating solely on the monetary side of what an accident costs, read the story at this link:

http://include.nurse.com/apps/pbcs.dll/article?AID=20005010330

Then think about how much MORE than money preventing an accident is worth!

That’s our lesson learned for this Monday.

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An article in the Akron Beacon Journal touts the value of automation in prevent human errors in hospitals. See:

http://www.ohio.com/news/43263777.html

Seems to be a good idea for some tasks. But what about others? Let me know your thoughts by leaving a comment here.

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This book review highlights the errors that haunt doctors. See:

http://www.nursinglink.com/news/articles/8058-a-doctors-soul-is-tormented-by-medical-errors

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TapRooT® instructors Tommy Garnett and David Davis will be presenting a 2-day Pre-Summit course, TapRooT® and FEMA for Healthcare Root Cause Analysis on October 5 and 6, 2009 in Nashville, Tennessee. TapRooT® Users will learn to use tools to perform JCAHO required healthcare FMEA as part of proactive risk reduction/performance improvement program.

Learn team-based, systematic, proactive approaches to identify how a process or design can fail, why it fails, and how to make it safer. These techniques can be applied to find and fix the root causes of issues to improve patient safety & stop healthcare sentinel events before they happen.

David Davis

Dave Davis is a Certified Nurse of the Operating room, and a Registered Nurse and retired U.S. Army Lieutenant Colonel. He has an MS in Nursing Services – Administration, and an MS in Operating Room Nursing. He is a previous consultant in infection control & disease epidemiology for the U.S. Army and is Certified as a DoD Healthcare TapRooT® Instructor.

Tommy Garnett

Tommy Garnett has 20 years of experience in Patient Safety & Risk Management. He is a Registered Nurse, a Certified Trauma Nurse, and a Flight Nurse. Tommy graduated from the American Institute of Medical Law, and is a licensed and Board Certified Healthcare Risk Manager. He is also Certified as a DoD Healthcare TapRoot® Instructor.

Learn more about the TapRooT® Summit on our webpage, or register for this course at: http://www.taproot.com/store.php?e=822

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A patient suffering from pregnancy induced high blood pressure walks into an Acute Care Clinic 5 Day’s after giving birth with the following symptoms (1):

* Fatigue and weakness
* Rapid heartbeat
* Shortness of breath (dyspnea) when you exert yourself or when you lie down
* Reduced ability to exercise
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness

The patient is sent home after a lung x-ray and with medicine to slow her heart rate down. Six hours later she is admitted to the Emergency Room by ambulance with the following symptoms (1):

* Fatigue and weakness
* Irregular heartbeat
* Shortness of breath (dyspnea)
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness

The patient is dropped off at the front desk to answer questions because she is able to sit up and speak. Finally the patient is paralyzed in order to be examined and the staff realize that she is having Congestive Heart Failure.

Two heart stops later, admission to the ICU and after fiver years, my wife, Babette, is doing okay… still gets tired but she did not need a new heart nor did she receive brain damage from lack of oxygen.

So what does this have to do with Root Cause Analysis and what I teach today…..

There must have been something “Different” with this patient… There must have been a recent “Change” in how to diagnose Congestive Heart Failure….

We have talked about performing a Change Analysis before on this site and we teach this in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader and Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis courses…. but what if you do not find a recent Change or Difference, how could you have prevented this from happening?

While the initial thought may have been these were abnormal symptoms (A Difference)…. the symptoms listed above are pulled directly from a well known medical clinic (1). Staff are trained to look for these issues and no Change was made recently in their processes.

So could you have proactively prevented my wife’s missed diagnosis and the findings listed below?

“Multivariable analysis showed that patients who presented to the emergency department with acute cardiac ischemia were more likely not to be hospitalized if they were women less than 55 years old.”(2) So is AGE enough of a a patient difference to understand what went wrong on January 5th, 2004?

The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! In all our TaprRooT® training courses proactive auditing is covered…. but what is the difference between a great audit and just watching someone work to see what policies and procedures they broke?

Go Out and Look (GOAL) and perform a robust audit. Knowing what you know now, what would you look for when auditing an examination of a patient in an Acute Clinic or the Emergency Room? Where would you start? What would you look for?

What critical Near Cause Categories could occur during this process in the timeline from Acute care clinic > ambulance > ER front desk ER > ICU (just to mention a few)…

Misunderstood Verbal Communication?

Turnover Needs Improvement?

No Communication or Not Timely?

Within each of these TapRooT® Near Cause Categories are Root Causes. So what would a Good Near Cause Category and Root Cause Best Practice look like…. the opposite of our definitions. By looking for these best practices during an Audit, you will find problems in you current unchanged process before it is too late.

So while performing an audit what is better and why… a surprise no notice audit or and a scheduled audit with plenty of notice…… I would love to see guests to the weblog and our TapRooT® students answer the above question.

After all The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! Why wait! Join us and other leaders in the industry in an upcoming TapRooT® training course to learn more about effective proactive auditing.
(more…)

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From the posting:

The Process Excellence Leader is responsible for assuring that systems and processes are in place to promote and facilitate continuous improvement activities across the entire organization. Working under the general supervision of the VP of Quality and Process Excellence, the Process Excellence Leader is responsible for leading and implementing a large and diverse set of process and quality improvement projects and activities. The ideal candidate will also be a good listener, motivator, innovator, communicator, advocate, and have a passion for making significant improvements.

For more info, see:

http://www.careerbuilder.com/JobSeeker/Jobs/JobDetails.aspx?IPath=ILKM&ff=21&APath=2.21.21.0.0&job_did=J3G2S966H570THVDQVF

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Dennis Osmer (one of our TapRooT® Instructors who also consults on Pandemic Flu) sent the following flu season update that I’m passing along to readers…

- - -

Dear Friends –

Seasonal Flu

This year there are higher rates of flu in Taiwan & in the EU, but lower rates in the US. Also, the dominant strain in the US is H1N1, but in Europe it’s H3N2, and in Canada influenza B is more common.

An article in “Emerging Infectious Diseases” (CDC publication) studied the use of face masks to control respiratory virus transmission in households and concluded the during a severe pandemic, transmission in households could be significantly reduced. Additionally, an article in the “American Journal of Infection Control” evaluated the performance of N95 masks after prolonged storage — the conclusion is that most respirators, shored for up to 10 years, will retain their performance.

An article in “Clinical Infectious Diseases” measured airborne influenza in a hospital emergency department, and concluded that there is evidence that influenza virus may spread though the airborne route.

An article in “Proceedings of the National Academy of Sciences” has found a link between influenza transmission rates and absolute humidity (with low humidity, influenza virus survival is prolonged and transmission rates go up).

VACCINE DEVELOPMENT

A team of researchers working in Japan’s Health Ministry have developed a new universal vaccine effective in many types of flu — trials in mice have shown promising results — but, human testing is still some time away.

WHO has announced it’s recommended composition for next year’s seasonal flu vaccine — while they considered including 2 influenza B viruses, they have stayed with the tradition of just one (though two virus types are known to co-circulate) — the recommendation (only changing the “B” part)  is:

- A/H1N1 - similar to A/Brisbane/59/2007
- A/H3N2 - similar to A/Brisbane/10/2007
- B component - similar to B/Brisbane/60/2008

H5N1

China
There have been 8 deaths (in 7 provinces) and several outbreaks in China so far this year — while the number sparked concern at WHO, there is no evidence of an epidemic — the cases were geographically scattered and sporadic. China is considered one the nations most as risk because it has the world’s biggest poultry population and many chickens are kept close to humans. Curiously, the Ministry of Agriculture states that it found no related, infected poultry. This could indicate another virus mutation which results in infected poultry with no virus symptoms.

Japan
Panasonic has taken the unusual step of ordering some of the families of staff assigned to parts of Asia, Africa, eastern Europe and South America to return home (to Japan). The press release indicated that the move was based on H5N1 pandemic concerns, but did not elaborate. Honda has requested employees to cut down on trips to China.

Other
A study, published in “Proceedings of the National Academy of Sciences” indicates that H5N1 is more virulent than the 1918 Pandemic strain. The H5N1 virus replicates faster and more widely in the lungs and caused a more intense inflammatory response.

Japan and New Zealand have announced plans to place their countries in quarantine should a pandemic occur.

Recent outbreaks have occurred in Vietnam, Egypt, and China.

A document, from the American Nursing Association “Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals during Disasters, Pandemics, and other Extreme Emergiencies”,  provides some helpful guidance.

While a dentist shouldn’t become a heart surgeon, some flexibility under extreme conditions is appropriate. They recommend following the National Incident Management System (NIMS) and using Incident Command, for an “all hazards” approach. Decision making during extreme conditions shifts the goal to the greatest good for the greatest number of individuals. This means that the “walking wounded” and the “worried well” might be unable to access medical care. This is endorced by ANA & the Joint Commission. It also allows for utilizing volunteers (based on their training) and provides for some ethical principles in emergency care — e.g.
- individual privacy may be overridden during emergency conditions.
- actions that impinge on individual liberty may be required, but should be clearly explained.

WHO data, below, shows an increase in the number of cases (now over 400) and deaths(256). Keep in mind that this is only data verified in WHO labs & that Indonesia is still withholding information.

I’m still convinced it’s smart to be informed and prepared.

Best Regards
         
Dennis

Dennis Osmer
Environment, Health, Safety, & Emergency Management
678-333-4230

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Here’s a link to a story in New Zealand about cataract surgery errors:

http://www.stuff.co.nz/southlandtimes/4862877a6568.html

So many similar events in a row. Was there a way to stop these errors faster? Should have they been prevented by redundant Safeguards?

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See:

http://hotjobs.yahoo.com/job-JFGUESRL9IA;_ylt=AtmU6WLXfR9UzcZsKz9WA8n6Q6IX?source=SRP

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Have you read about the benefits of a surgical checklist?

If you would like to know more and talk to people who wrote “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population“, then go to this link:

http://www.ihi.org/IHI/Programs/ImprovementMap/ImprovementMap.htm?TabId=3

  Don’t wait! The first phone in Q&A session is on February 20.

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Here is an interesting article about the performance of nursing homes:

http://www.telegram.com/article/20090215/NEWS/901300279/1116

We hear a lot in the news about medical mistakes, but we do not often hear of the vast list of nursing home issues; the article discusses everything from patient injuries to security problems and food quality.  The common denominator to these problems is that they all appear to relate to a lack of systems and best practices - these problems can be solved by using TapRooT® to identify the missing practices and install standards, policies, and administrative controls to address them.

Nursing home administrators; attend a TapRooT® course today - here is the schedule:

 http://www.taproot.com/courses.php

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Set the stage for reducing error at your healthcare facility! Root cause analysis is a superior tool that can help you implement meaningful and positive changes in any patient care system.

Join us at the 2009 TapRooT® Summit (October 7-9 in Nashville, TN). Our Best Practice Track “Eliminating Hospital Sentinel Events” offers sessions that will change the way you think about approaching medical error reduction. The real payoff comes when you return to your facility with revolutionized knowledge to develop and implement effective steps that everyone can take to prevent future problems.

Debra Smith

“CSI: Stanly” is one of three engaging presentations planned for the Healthcare Root Cause Analysis Best Practice Session on the Eliminating Hospital Sentinel Events Track. During this session, Debra Smith, Senior Vice President & COO, Stanly Regional Medical Center, will do a practical review of the use of TapRooT® tools in the every day investigations of patient events. Examples will range from the serious (a sentinel event) to those on the lighter side (family assisting a behavioral health patient escape from the facility).

LEARN MORE about Best Practice Presentations planned for the Eliminating Hospital Sentinel Events Track at the TapRooT® Summit by downloading our brochure!

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Here’s a link to an interesting article about root cause analysis, blame, fraud, and politics in the healthcare industry in New Zealand:

http://www.odt.co.nz/opinion/opinion/41605/blame-and-shame-approach-ill-founded?page=0%2C0

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49 accidents (Sentinel Events) in Queensland Hospitals in 2006-2007.

Listen to this story from ABC Australia:

(click to listen - mp3)

Now ask…

Can we compare Sentinel Events rates across countries?

What national, consistent system do we have in the US?

Is a medical error a political issue or a medical issue?

Shouldn’t the story be about why the errors occur or the slow pace of performance improvement?

Comments are welcome below by clicking on the comment link.

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TapRooT® Instructor Dennis Osmer (who also consults on PANDEMIC FLU readiness), sent the following update on the flu season:

Dear Friends –

SEASONAL FLU — US
       
According to the CDC, seasonal flu in the U.S. is below last year’s infection rate & the cases are tracking closely to the virus strains contained in this years vaccination — good news except for 2 points:

(1) Approximately 38% of the identified cases are H1N1 (the dominant strain), yet this is resistant to Tamiflu (no worries if you were vaccinated) — CDC is issuing guideline to practitioners to deal with this (the complication is that antiviral medication is needed within 48 hours of symptoms, yet lab tests to identify the specific virus type can take over a week) .

(2) While the vaccination contains only one type of influenza B, there are two distinct viruses in circulation — this may lead to next year’s vaccination being quatravalient (2 subtypes of influenza A & 2 subtypes of influenza B).

While vaccination rates increased this year, CDC remains concerned about school age children, who bear a significant burden of seasonal flu — several states have experimented with school based influenza vaccination programs (free) and demonstrated that these programs (Stop The Flu at School) were cost effective — expect expansion of this program next year.

SEASONAL FLU — UK

Influenza cases are surging in England, raising concern that the country could have its toughest season in a decade — The British Medical Association and the Royal college of General Practioners is requiring doctors to set-up wating rooms to seperate patients with flu from those not infected, and has also issued guidance on face masks, and getting people to self-quarantine at home.

PANDEMIC FLUs

Hawaii  has instituted flu-like illnesses screening of all arriving international travelers  — they use a combination of thermal imaging & questionaire — if fever is present, the passenger is then seen by specially trained medical personnel.

Korea has also instuted screening for everyone entering via airport or harbor — after medical screening, it is possible to be restricted to a quarantine facility.

Indonesia, which has be withholding tissue samples & data since 2006, has announced that they plan to eliminate bird flu by 2014 — no plan details were made available — WHO & CDC remain skeptial — Indonesia has belatedly confirmed 2 more fatalities from H5N1, bringing the confirmed number of deaths to over 250.

A new map is available on the Internet  www.healthmap.org  which tracks all major illness outbreaks globally — it’s amazing how much is going on out there.

Sporadic human infections with H5N1 continue to occur — recently there were 4 cases in China (in various provinces) all of whom had contact with infected poultry or ducks — over 200 people are now under observation due to close contact with infected people — WHO & CDC continue to call on China to release more epidemiological information  — China has an aggressive poultry vaccination program with 11 billion applications per year (at any point in time, China has roughly 5 billion chickens, 700 million ducks and 300 million geese).

H9N2 has surfaced again in Hong Kong, however the current strain is much less pathogenic than H5N1.

While handwashing has been recommended as a major practice to reduce the spread of flu, we now have the results of a scientific study by WHO and several hospitals in Australia — the test use the H1N1 virus — both Soap & Water and Alcohol (>60%) based hand rubbing were highly effective in reducing the influenza virus on human hands.

By staying informed and taking actions, we can survive.

Best Regards
           
Dennis

Dennis Osmer
Environment, Health, Safety, & Emergency Management
678-333-4230

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Eight hospitals reduced the number of deaths from surgery by more than 40% by using a simple 19-step pre-surgery checklist.

http://www.medicalnewstoday.com/articles/135487.php

The report in the New England Journal of Medicine says that if all hospitals adopted the checklist, they could save tens of thousands of lives and $20 billion ANNUALLY. 

This same article appeared in the January 15 edition of USA TODAY.  This article goes on to state that:

- Surgeons are good at making sure they do most of the things most of the time, but not very good at doing all of the things all of the time.
- An operation’s success depends far more on teamwork and communications skills than on an individual surgeon’s skill.
- The checklist takes about 2 minutes to complete.
- It is modeled on checklists used on the aviation industry.
- The checklist has nothing to do with high tech solutions, instead focusing on basic safety measures.

It is almost frustrating to read an article like this.  TapRooT® has been teaching these exact principles for 20 years, and now the World Health Organization funds a study that repeats exactly what our TapRooT® investigators would find if they had conducted their own investigation.  In fact, after reading the article, I’d swear the author had just attended a TapRooT® course.  You can scan through this article and attach the TapRooT® root causes directly to his individual statements.

Luckily, I’m more of an optimist.  This study proves that we can make a difference and save lives right now.  Even the most basic TapRooT® investigations have the opportunity to fnd and correct these types of relatively simple mistakes.  All we have to do is DO IT!

New England Journal of Medicine article:
http://content.nejm.org/cgi/content/full/NEJMsa0810119

Checklist (including video of proper use):
http://www.who.int/patientsafety/safesurgery/en/index.html

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US carriers have gone 2 years without a passenger fatality. Here is the story:

http://www.cnn.com/2009/TRAVEL/01/12/us.air.safety/index.html

As someone who worked for airlines for 27 years (the last 10 in safety and compliance) before joining System Improvements, I can attest to the professionalism of all the employees, from mechanics to pilots to operational folks and beyond.  Safety is ingrained in the culture of this industry; after all, the smallest problem can be devastating.  Congratulations to all the airline employees, suppliers, manufacturers, and air traffic controllers for getting it right over and over, day after day.

On the other side of the coin, medical mistakes have been blamed for thousands of deaths per year in the US.  The same best practices for human performance used by the airlines and countless other industries can be used to reduce this alarming problem. 

The Joint Commission http://www.jointcommission.org/AboutUs/ is working to address these issues, but the data clearly shows there is a long way to go. In the meantime, at least you can feel good about getting on an airplane, as long as you don’t eat the food!

Healthcare Professionals - take a stand and fight against these preventable errors!  Attend a TapRooT® course in 2009 - here is the schedule:

http://www.taproot.com/courses.php
 

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According to the article. there has been a 100 percent increase in injury reporting from Wii users… 100%!? So what are the symptoms:

… tendon stretching
… possible arthritis or rheumatism in later life
… “Wii-Knee” with the knee becoming dislocated or pooping out of joint

So is the cause the Wii and if you get rid of it you won’t get hurt? Nope just plain health issues. By the way I saw another news release where senior citizens use Wii to simulate bowling. So before you graduate to Wii start with Pong and then work your way through PacMan… Stretching and taken breaks in between games. Blame was arrived to quickly again.

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I’ve had several healthcare professionals ask me about SBAR communications and I found a link to a publication by the Arizona Hospital & Healthcare Association that might be of interest.

See:

http://www.azhha.org/patient_safety/documents/SBARtoolkit_000.pdf

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Radiologists are being trained on iPods. Watch the video from the BBC at:

http://news.bbc.co.uk/1/hi/england/7777797.stm

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Interesting article - training, fatigue, and hand-offs are all discussed:

http://well.blogs.nytimes.com/2008/12/02/panel-calls-for-changes-in-doctor-training/#more-344

Healthcare professionals; how about a 2 or 5 day TapRooT® course for the New Year?  See course schedules at http://www.taproot.com/courses.php

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An article in the Daily Telegraph said:

“The report said a major theme in unexpected deaths and serious incidents - listed in the reports as root cause analysis (RCAs) - was ‘delay in recognition and management of the patient.’”

The article delves into a 20% increase in the number of avoidable deaths at western Sydney hospitals.

Perhaps they need advanced root cause analysis?

Hospital performance improvement personnel should attend one of our TapRooT® Courses in Australia.

To see upcoming courses, click on Oceania on the map at:

http://www.taproot.com/courses.php

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Previous posts about a pilot being removed from the cockpit after suffering a “mental breakdown” were posted back on February 5 and November 20.

Much of the industry press seems to downplay the safety importance of this event.

For example, here’s a pod cast on the topic:

(from Airsafe.com)

Despite the reassurances (”there have been no passenger deaths or serious injuries associated with incidents where such behavior was proven“) from the Airsafe.com spokesperson, I remember that the NTSB investigators were convinced that an EgyptAir 767 crash in the Atlantic was almost certainly due to a pilots deliberate actions. (The story says: “On 31 October 1999, an EgyptAir 767 en route from New York to Cairo, crashed in the Atlantic, killing all 217 on board. The NTSB concluded that the airplane’s departure from normal cruise flight and subsequent impact with the Atlantic Ocean was a result of the first officer’s flight control inputs, but could not determine a reason for the first officer’s actions.“)

I read the complete NTSB report and the only logical conclusion was that the co-pilot deliberately crashed the plane. Anyone who would deliberately crash a fully loaded jet must be considered “mentally abnormal”. (However, if you read the report you will see considerable objections to the deliberate suicide scenario by the Egyptian investigators. I think these objections are countered by the evidence in the report. But you can draw your own conclusions after reading the report.)

Thus my conclusion is that in this case, there HAS been a case where a flight originating in the US was deliberately crashed by an unstable pilot. I think that the Airsafe.com spokesperson on the pod cast is overaly reassuring when he said:

“…there have been no passenger deaths or serious injuries associated with incidents where such behavior was proven”

A more accurate statement is that “there have probably been two prior accidents caused by mentally abnormal pilots but that these types of problems are very difficult to prove.”

So what is the lesson learned?

That a pilots mental stability really is important. A mentally unstable pilot really is a major problem.

But what can we do? That’s not very obvious.

You might start thinking about what your company does to assess the mental stability of people in key jobs that could cause major accidents with loss of life.

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“NEW YORK, New York, November 24, 2008 (NBC) — A woman, who entered a New York hospital with what she thought was a kidney stone and left a quadruple amputee, has filed a multi-million dollar malpractice suit.” Read the article here: http://www.ksn.com/news/also/35005814.html.

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Thought I would pass along this e-mail from one of our TapRooT® Instructors, Dennis Osmer. he also does work on pandemic flu planning and I thought that TapRooT® Users might find this interesting…

- - -

Dear Friends –

                Hope all of you in the U.S. had an enjoyable Thanksgiving!

                According to CDC, seasonal flu in the U.S. is below last year’s infection rate & the cases are tracking closely to the virus strains contained in this year’s vaccination — both are good news!

              Indonesia continues to restrict information about H5N1 — while Indonesia is arguably the world’s top spot of avian influenza activity, we have no official word on how rampant the virus is — Japan has sent a medical team to assist local health personnel and also monitor the flu — the most recent, unconfirmed reports are that an additional 17 people have died due to H5N1 (this will NOT show up on WHO statistics, as it can’t be confirmed via lab samples).

              WHO is in the process of updating it’s definitions of pandemic phases, adding more emphasis on social and economic effects, as well as reflecting scientific advances and increased practical experience — while still in draft, the revise level 5 is “established human-to-human transmission in two or more non-contiguous countries in one geographic region” and phase 6 is “has caused clusters of disease in at lest two of the continents …” — they are also adding several defined phases beyond level 6:

                                - post-peak period
                                - possible new wave
                                - post-pandemic period

The new phases are currently unnumbered.

                U.S. Dept. of Transportation has released 5 guidelines that will provide rules for aviation, highway, maritime, mass transit & railroads during a pandemic — if your business or employees depend on any of these transportation modes, you may want to review to ensure your own BCP is in alignment.
                 

www.pandemicflu.gov/plan/pdf/cikrpandemicinfluenzaguide.pdf

                Migrating waterfowl are suspected of carrying various influenza viruses — now the USGS and U.S. Fish & Wildlife Service have confirmed, thru genetic evidence, that this is true –  the connection between eastern Asia & North America is validated.

                Google has announced a new site that tracks flu activity — studies show that 35 - 40% of all internet inquiries are begun by people looking for health information — many people with flu, never visit a doctor — studies indicate that internet activity data is about 2 weeks ahead of the CDCs seasonal flu tracking and is therefore, a good early warning  — www.google.org/flutrends

                The University of Michigan conducted a study of non-drug flu defenses — it found that wearing an N95 mask and using an alcohol based hand sanitizer can cut flu transmission by up to 50%  - One of the negative findings were that people didn’t always take the time to ensure mask fit — This clinical evidence is good news, but also indicates that multiple, overlapping strategies (i.e. social distancing, self-quarantine, etc.) are necessary.

              By staying informed and taking actions ahead of the crowd, we can survive.

Dennis Osmer
Environment, Health, Safety, & Emergency Management
678-333-4230

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Following up on our November 21st post about a “not preventable” virus outbreak at a UK hospital, there is another report in the Yorkshire Evening Post about two babies with the Super Bug at St. James’s Hospital.

To read the complete story see:

http://www.yorkshireeveningpost.co.uk/news/Two-babies-in-Leeds-care.4744284.jp

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From the Posting:

Job Description

“The Root Cause Analysis & Process Improvement Business Analyst will be responsible for conducting root cause analysis on errors identified through the Claims Quality Assurance (CQA) Program to identify additional training needs and / or to link to process improvement initiatives. The Business Analyst will enable UAC to determine the root cause of errors and will provide supporting information (including proposed solution option(s)) to allow UAC Senior Management to make a determination on the appropriate action for remediation of identified issues to improve overall financial and procedural accuracy, as well as increase operational efficiency. The Business Analyst will be responsible for researching and identifying the root cause of issues and recommend solution that may involve one or more of the following: process redesign, training, system or policy changes, employee recognition programs, etc.. The Business Analyst will report directly to the V.P. of Medicare Advantage Operations Command Center and will have dotted line responsibility to the V.P. of Quality Assurance and Process Improvement.”

For more info, see:

http://hostedjobs.openhire.com/epostings/jobs/submit.cfm?fuseaction=dspjob&jobid=287929&company_id=15763&version=4&source=Indeed&jobboardid=1112

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To read the whole story, see This is Wiltshire, UK.

The story says that the report claimed the outbreak was “not preventable.”

Yet the Wiltshire Primary Care Trust Board minutes of the October 21, 2008 quotes the trust’s Joint Director of Public Health PCT/WCC as saying: “… norovirus was not preventable except via good hygiene.”

So is good hygiene not possible?

OK healthcare professionals … What’s the story here? Leave your comments by clicking on the comment link below.

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Read this article about a recent nursing home incident and post-incident discipline:

http://www.nursinglink.com/news/articles/6093-nurse-pays-for-her-good-deed

Now think about this:

1. Was a complete root cause analysis performed?

2. Was discipline an appropriate corrective action?

3. Did performance improve as a result of using discipline as a corrective actions?

Leave your comments by clicking on the comment link below.

Thanks

Mark

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The article states that Sergeant Tara Norton, who assisted the coroner, asked that:

“… he recommend that statewide education be provided for all medical officers on reportable incident briefs and root cause analysis investigations …”

For the rest of the story, see:

http://www.illawarramercury.com.au/news/local/news/general/death-of-berkeley-man-avoidable-inquest-told/1347004.aspx

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From a story in the Star Phoenix:

Health officials in northern Alberta will soon be testing up to 2,700 patients for HIV and hepatitis after a manager at the High Prairie hospital discovered some staff were routinely reusing syringes in patient IV lines - in some cases, for the last 18 years.

To read the story see:

http://www.canada.com/saskatoonstarphoenix/news/story.html?id=d9249f6f-2e32-4179-a19e-506f21208b55

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