Category: Medical/Healthcare

Is Having the Highest Number of Serious Incidents Good or Bad?

March 6th, 2018 by


I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

Are you planning to attend the 20th Annual IHI/NPSF Patient Safety Congress in Boston?

February 20th, 2018 by

Per Ohstrom and I are looking forward to going to Boston, May 23 – 25, for the 20th Annual IHI/NPSF Patient Safety Congress. If you’re attending, please make a note to stop by the Exhibit Hall and visit us in Booth #316.

Healthcare facilities need multiple levels of analysis to truly identify the causes of patient safety related incidents. We’d love to talk to you about how TapRooT® offers robust data gathering tools and consistent objective root cause analysis to help you build the most effective corrective actions that will address and prevent problems. These tools all working in harmony with your systems will create a much safer environment for patient care.

We hope to see you there!

2018 Global TapRooT® Summit Patient Safety Track

February 12th, 2018 by

The Patient Safety Track is for healthcare professionals and those interested in healthcare. Michele Lindsay shares about what you can expect when you register for this informative track.

Register for the Patient Safety Track.

Learn more about the Summit.

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

January 12th, 2018 by


Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.


Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:


Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.


Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.


Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.


Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.


Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.


TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

This is “National Hand Washing Awareness Week”

December 6th, 2017 by

Want to prevent infections? Wash your hands!


A press release from the Henry the Hand Foundation

National Handwashing Awareness Week Dec 3-9, 2017

In a recent article in New England Journal of Medicine  “Chasing Seasonal Influenza”  it was reported …according to the Australian Government Department of Health. Influenza A (H3N2) viruses predominated, and the preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%. The implications for the Northern Hemisphere are not clear, but it is of note that the vaccine for this upcoming season has the same composition as that used in the Southern Hemisphere.

BUT, No need to worry because in 1999 during first Flu vaccine shortage a community wide coalition created events promoting handwashing with coloring contests throughout schools and community centers and ended during the first National Handwashing Awareness Week! Result was one of the healthiest year for our community!


Share the National Handwashing Awareness Week poster with everyone you believe could benefit!! And an additional bonus is True Flu Prevention poster for those who do NOT want the flu or flu-like illness!!

Our latest innovation is the first portable self teaching Hand Hygiene Learning Center that helps students train themselves. Sized for Early Childhood age group and one for larger students, as well! Put it outside the Classroom, in the cafeteria, playground or wherever there may a norovirus/shigella outbreak!

There is a Classroom Tool Kit included to help your students sustain the habit! The addition of the Tool Kit can help train your staff, students and their families with the tools to keep them healthy year round by practicing Henry the Hand’s 4 Principles of Hand Awareness.

The BEST science-based, multi sensory curriculum in a Tool Kit that is so easy to understand it teaches itself! Your gift for Global Handwashing Day!!

In the  Science of Habit, Dr Jelena Vujcic discusses the two critical components around habit : first, creating a good habit and second, is sustaining the habit. However, sustaining the habit is the more difficult component to achieve!

Visit the Henry the Hand Website.

What Does a Patient Want After a Medical Error?

November 8th, 2017 by

Of course, a patient would prefer that a medical error NEVER happens. Thus most people want the hospital they attend to have a great performance improvement program that proactively PREVENTS errors from occurring. However, even with the best programs, an error is still possible (even if it is highly unlikely).

A study in the JAMA Internal Medicine says that patient’s and their families want physicians and hospitals to communicate with them to explain what the facility is doing to prevent similar future incidents. We are going to try harder is not enough. They want real root cause analysis with effective corrective actions.

The study said that “Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.”

So what do patient’s want?

  • Adequate compensation
  • Friendly communication
  • To be heard by the physician and the hospital.
  • How the hospital/physician would prevent future errors

If you don’t have advanced root cause analysis you can’t meet the patient’s expectation.

Maybe it is time to learn about TapRooT® and start your facilities journey to world-class root cause analysis and performance improvement?

More Proof that Hospitals Need to Improve Root Cause Analysis

November 6th, 2017 by

What would you think if your hospital received a “D” in a Leapfrog hospital rating? THIS ARTICLE points out three hospitals in the Atlanta area that received the worst Leapfrog scores.

My response would be that they need better root cause analysis. With advanced root cause analysis they would be finding the causes of infections, treatable complications, unnecessary blood clots, collapsed lungs, air or gas bubbles in the blood, and other preventable errors.

Effective root cause analysis is the basis for an effective performance improvement program. Without effective root cause analysis, a hospital is doomed to repeat their errors because they are guessing at solutions.

Want to find out more about the 5-Day Advanced Root Cause Analysis Training? See:

The NHS in the UK Provides Guidance on Learning from Deaths

October 24th, 2017 by

Learning from Deaths

What guidance does the document provide? Here’s the table of contents:


The NHS has also established the Healthcare Safety Investigation Branch (HSIB) to perform independent investigations of unnecessary patient deaths. For more information about the HSIB, see:

Monday Accidents & Lessons Learned: Five People Die After Using Weight Loss Balloons

September 18th, 2017 by


According to the Food & Drug Administration’s report, five people have died since 2016 after being treated with weight loss balloon devices. The science behind this technology is that the balloon takes up space in the stomach after being filled with solution and this leaves less room in the stomach for food. The balloon is left in the patient’s stomach for six months while the patient learns to eat differently.

The five deaths occurred within a month of balloon placement.  We know that four of the deaths involved a balloon from the same manufacturer. However, nothing has been found linking the deaths to the medical device. In the TapRooT® System, an investigator would examine an incident like this by first creating a sequence of events. Once the sequence of events is completed,  more information would be collected.  For example:

Did the patient understand the risks?

Was the patient closely monitored by the healthcare team for possible deteriorations?

Did the patient understand which symptoms required medical assistance?

These are just a few of the types of questions that should be answered to help determine all the Causal Factors. There could be multiple things that went wrong. TapRooT® doesn’t stop at Causal Factors. Each Causal Factor is taken through the TapRooT® Root Cause Tree to find the Root Causes. Just like there may be (and probably is) more than one Causal Factor, there is probably more than one Root Cause that needs to be fixed to prevent this from happening again.

Mark Paradies recently posted an article that may be helpful in a situation like this, “Root Cause Analysis for the FDA.”

It takes some deep diving to understand all of the lessons learned here. Learn more about how to prevent unnecessary deaths like this in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

Building a Safety Culture

May 26th, 2017 by

A Safety Culture can be defined as “the sum of what an organization is and does in the pursuit of safety”. Managing company culture is a task of the corner office; top management needs to embrace the safety mindset -that every employee and customer is free from harm.

In the health care field The Joint Commission (an accreditation organization for hospitals) takes patient safety very seriously. Their document, “11 Tenets of a Safety Culture” ( contains a lot of wisdom that can be applied in continuous safety improvement everywhere:

  1. Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions.
  3. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
  4. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop).
  6. Determine an organizational baseline measure on safety culture performance using a validated tool.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
  10. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.

A formal safety culture statement like this is a good start. To avoid it becoming a “flavor of the day” initiative, it is important to put in place a robust root cause analysis method like TapRooT®. This lends immediate support to Tenets 1. and 2. above.  It is also important to empower employees at every level to stop risky behavior.

Every organization benefits from an objective and impersonal way of investigating or auditing safety incidents, that gets to the root causes. Instead of blaming, re-training or firing individuals more effective corrective actions can be implemented, and safety issues dealt with once and for all.


Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at

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.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

Here are the 11 tenants they suggest:


To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

And then healthcare executives could also insist on advanced root cause analysis.

The Blame Culture Hurts Hospital Root Cause Analysis

November 22nd, 2016 by

If you don’t understand what happened, you will never understand why it happened.

You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?

I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.

Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.

Screen Shot 2016 11 22 at 11 09 45 AM

If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?

This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.

The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.

TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.

Foe course information and course dates, see:

Infection Control: Corrective Actions Much More Expensive then Proactive Improvement

October 3rd, 2016 by

Infection 2

Here’s a story about a healthcare facility who has agreed to hire an infectious control consultant as part of an agreement to fix problems found by regulators.

What I found interesting is that the original inspection found “11 years of misconduct that led to the contamination of surgical instruments, among other issues.” What this really tells me is that no one was looking at normal day-to-day practices at the center. If there had been a robust audit and observation program, they probably would have been able to do their own internal improvements at much lower cost and without the attendant loss of confidence in their facility.

Learn about using TapRooT® proactively in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Monday Accident & Lessons Learned: Baby Dies After Oxygen Mix-Up at Hospital in Australia

September 12th, 2016 by


Here’s a link to the story:

An Oxygen line had been improperly installed in 2015. It fed nitrous oxide to a neonatal resuscitation unit rather than oxygen.

The Ministry of Health representative said that all lines in all hospitals in New South Wales installed since the Liberal government took over in 2011 will be checked for correct function. 

What can you learn from this?

Think about your installation and testing of new systems. How many Safeguards are in place to protect the targets?

Blame Culture: Doctors Can’t Discuss Errors

August 31st, 2016 by

Perhaps they should be learning how TapRooT® stops blame and finds real root causes that can be corrected.

Medical Errors: Are You Preventing Pressure Ulcers?

August 26th, 2016 by

Medical Error Prevention

My wife was in a cast a few years ago. After about a day, she noticed it was itchy on the bottom of her foot, near her big toe. We didn’t think anything of it (never in a cast before). When we went in for a checkup after a few days, she told the doctor. They pulled off the cast and found a blistery area on the bottom of her foot. It was caused by a slight pressure from a bump in the cast, which cut off blood flow to that small area on the ball of her foot. It ended up being pretty minor (big blister the size of a half dollar), and it healed up just fine.

I was amazed to find out that this can be fairly common after only a few hours in a stationary position, for example, during surgery. They can turn out to be very painful and potentially disfiguring. DO NOT, under any circumstances, Google for pictures of pressure ulcers!

Here is a guide on how the medical community can help prevent pressure ulcers. It is meant to be a proactive means of looking for opportunities to prevent or detect the circumstances and risk factors associated with perioperative pressure injuries.

Hand Hygiene: Patient Safety Through Infection Control

August 24th, 2016 by

Hand Hygiene_Patient Safety Through Infection Control

I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.

How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.

Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances.  It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.

The Joint Commission Summary of Sentinel Events – 2Q 2016

August 22nd, 2016 by



Here’s a summary for reported sentinel events for the 2nd quarter of this year, compiled by The Joint Commission. It also compares some of the data against previous years.
It is almost impossible to make accurate comparisons on this data, since all reports are voluntary and, as stated in the report:

Data Limitations: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Without knowing who is reporting, who is not reporting, how these numbers are compiled or arrived at, how the problem types are assigned, etc., I’m having a tough time viewing the data in an objective light.

While the data is interesting, I’m not sure how this data is used.  Can anyone give me an example of how the data in this summary might be used?

Ed Skompski invites you to the Medical Track at the 2016 Global TapRooT® Summit

July 11th, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks. This video introduces the Medical track for healthcare professionals. Come to the Summit and maximize improvement at your company!

REGISTER for the 2016 Global TapRooT® Summit.

Interested in the Investigation Track? Learn about it here!

Interested in the Asset Optimization Track? Learn about it here!

Interested in the Safety Track? Learn about it here!

Interested in the Quality Track?  Learn about it here!

Healthcare: Can’t See the Forest for the Trees

July 5th, 2016 by


My grandmother (with whom I spent many of my childhood weekends) would say to us grandkids, “You can’t see the forest for the trees!” That usually came right after something bad happened or we did something that was not considered “right” by the adults. I always wondered what that meant, I have thought about it for years and I believe from an adult perspective I finally get it… Granny Lillie, if you can hear this, “I FINALLY GET IT!” (I hear her saying, “It is about time……sheesh.”)

As I have worked with healthcare organizations over the past 20 years working to improve performance and improve their systems we always talked about examining failures and finding the causes. Finding the “Whys” is the step necessary for you to fix issues that existed. Those issues that underlie our systems and turn into incidents, accidents and breed adverse behaviors have to be removed following a problem so that we can prevent reoccurrence. This is preached, taught, and required by all organizations in today’s business world. But why do we wait, why do we have to fail to learn? That question has always concerned me. This is where my grandmother fits in…

When as kids we would go out, make decisions to do things that had adverse outcomes, she would always say to us “you can’t see the forest for the trees” and we would just nod our heads and say “ok” then continue on our merry way. Not only would we not learn from our mistakes but we could not see the mistakes and incidents they happened. The correlation in today’s adult world from an organizational perspective relates to making decisions without considering the consequences. The “Trees” from the statement above is the change you are going to make. If you focus on the “Trees” in front of you and do not consider the future beyond that “the Forest” you are taking unnecessary risk and possibly creating problems. Do you “get it”?

What got me thinking about this today came from an article  I read which dealt with an investigation by the State’s Office of Inspector General at a Louisville, KY hospital. This along with the TJC visit which found many problems at the facility prompted concerns. The investigation was prompted by complaints by staff (that survived the downsizing) regarding health and safety issues due to the decreased staffing. After reading the article I immediately began thinking about our Proactive Flow within the TapRooT® process.

Proactive Flow
We talk about being Proactive in place of reactive and one thing I always mention in my classes is using the TapRooT® process to look at the process before a change or implementation and after that implementation to see where there may be gaps or issues that are identified. This proactive approach may raise questions before you commit to change.

Notice that when we get to step 3 in the Proactive flow we take the observed issues or problems and ask the simple question, “What could result from this?” We would pose this question against our view of the future system. Let’s suppose that they had recognized these future conditions:

  1. A reduction in staffing would create a significantly higher workload for existing staff
  2. Hospital maintained customer/patient throughput with reduced staffing
  3. Using traveling nurses with little or no facility or system related training to supplement staffing levels
  4. Reduced staffing could cause difficulty in maintaining the Quality Control standards due to pressure based on census

We can now take this information and use that “What could result from this?” and we could have had this conclusion:

Now notice that the Significant Issue identified has a dotted line around it meaning it is an assumption, but the possible outcome that could have been recognized (which later became a reality) could have been taken through the Root Cause Tree® and analyzed before it became a reality. And you would have likely come to several areas on the back of the Root Cause Tree®:

a) Training – No Training – Decided not to Train
b) Management System – Standards, Policies and Administrative Controls NI – Not Strict Enough
c) Work Direction – Preparation – Scheduling NI
d) Work Direction – Selection of Worker – Not Qualified

And there certainly could have been others. At this point you have the ability to re-evaluate the changes you are about to make and ensure that the programs put in place following this down-sizing remove these potential problems. This allows you to evaluate the “Forest” behind those “Trees” and ensure the safety of your future patients and staff while working through the “Forest.” If this one hospital had performed this analysis the outcome and where they are today could have been significantly different.

By using this thought process and by being Proactive we can all create safer systems, create a more effective and acceptable working environment, and protect those around us that depend on us… just as Granny Lillie tried to do for us kids so many years ago. Sometimes the simplest, most practical viewpoint is the best. If you have any questions about the TapRooT® process for Proactive assessments please contact me directly at

Can Healthcare Benefit from Procedure Usage?

June 27th, 2016 by


Don’t think checklists are useful in healthcare? Read on!

I was teaching a class (not in the healthcare arena) and had some interesting discussions around the use of procedures during work. First let’s recap the TapRooT® Definition of a procedure:

A procedure is a written step-by-step description of how a particular task is to be performed that is read and followed during performance of the work by the person performing the work.

A checklist is considered a procedure in our system. For this company there were two perceptions regarding procedures and their uses:

  1. Those are only necessary if there are people who are not knowledgable on the task.
  2. Those procedures always make work more difficult.

Now, I have heard these comments before from folks in the healthcare field when the work procedure is used not for a medical “procedure” but when it is used as a checklist. Many doctors and nurses don’t like having to follow a specific path towards medical treatment. And I agree because each human is different, each course of treatment is different, and every scenario is different that it is more difficult to set procedures for every medical treatment. But can tasks and scenarios benefit from the use of checklists within healthcare?

The following article talks about the use of checklists and examined 10,700 surgical procedures. The results although only showing small decreases did show that the implementation of quality checklists dealing with Surgical Safety reduced the following:

Length of Stay from 10.4 to 9.6 days
30-day Readmission Rates from 14.6 to 14.5%
90-day Death Rates from 2.4 to 2.2%

Small numerical changes equate to large numbers in the overall scheme of healthcare. From a 2010 National Hospital Discharge Survey and the National Center for Health Statistics showing some 51.4 million inpatient surgeries performed, that means that we can reduce the number of readmissions by 51,400 patients, and the 90-day death rate means we lower the number of deaths by 102,800 patients. Now I am not sure if you agree but that is a SIGNIFICANT impact on patient care. Those are numbers that could provide pause for those who don’t think checklists can be used in healthcare!

Now going back to our two objections above, let’s now think about why procedures, when implemented and designed properly, can improve performance.

Those are only necessary if there are people who are not knowledgeable on the task.

Procedures can be built to contain a level of information that can be helpful to both experienced and non-experienced practitioners. The idea that just because you have a lot of experience that you cannot make a mistake is unacceptable today. We are fallible, we are human, so why can’t we accept help? I believe it is perception, see comment 2 above:

Those procedures always make work more difficult.

Perception is reality and if people don’t believe or understand why you implement these checklists and don’t implement them effectively then this is understandable.
Here is what checklists help you do:

  1. Not rely on short-term memory
  2. Become more consistent in an approach to a job
  3. Remind and caution against unsafe behaviors
  4. Document the way work is “expected” to be performed

These four items alone are work an additional 2-3 minutes of time it takes to address and use the checklist, don’t you think?

From the numbers above, and the possible impact on patient care the use of checklists where reasonable is a very simply and effective way to raise the level of performance of your staff and have a very positive impact on patient care. If you would like more information on this or other topics around the TapRooT® system and how it impacts human and equipment performance please feel free to contact me at

Handwriting and RCA

June 20th, 2016 by

Today’s article is meant to create a discussion. We all know that Electronic Medical Records (EMR) are taking the place of written orders in healthcare (providing their own set of issues), so where does the written word fall on the Root Cause Tree®?

The cartoon below illustrates the issue we are discussing:

Back in the day doctors and nurses always used written records, or prescriptions. Today the reliance on this form of communication is less than in the past but can still cause issues. One question to ask yourself is, “Is the burden of understanding written communication on the writer or the reader?”  What is your opinion on this? Mine is that it is most certainly on the writer. We should not provide communications of any kind that have to be interpreted to be understood. Going back that is why many acronyms have been removed from healthcare…they simply created confusion.

So thinking about written communication, if we have a Causal Factor dealing with a nurse or physician did something wrong due to a misunderstanding of a written communication…where would we go under the “Human Performance Difficulty” section?

One question that would most likely be a yes is the second question under the Team Performance Section: Did failure to agree about the who/what/when/where of performing the job play a role in this problem?. This leads us to Training, Communications, and Work Direction but does that really match?

For this week please provide your insight into where you believe this issue would fit. Thank you for reading and for providing your insight! I will write about our results in next week’s article! Have a great week……

(P.S. Don’t forget to sign up for my Medical track at the 2016 Global TapRooT® Summit, San Antonio, August 3-5, 2016.)

When is a Root Cause NOT a Root Cause to a Sentinel Event

June 13th, 2016 by

So many times when I review Sentinel Event (SE) analyses for companies, I struggle to find the link between a Root Cause and the data on the SnapCharT®. But at the same time, the Corrective Action provided for that cause makes sense to reduce the likelihood of recurrence. This is perplexing as I did not want to say that the analysis was done poorly or was not correct simply because the outcome would probably be a positive one. Then it hit me, many people when going through the Root Cause Tree® were focusing more on the outcome desired than what the data told them.

Our ultimate goal is to fix a problem, reduce risk, and keep our patients, patients’ families and staff safe. To do so we have to present a very coherent, logical argument back to our administration regarding our analysis and findings. I represent this with the following diagram:

Specific Relationships
There is a “Specific” relationship between an Incident, the related Causal Factors, the Root Causes of those Causal Factors, and the Corrective Actions we recommend. This relationship has to be easily seen by your audience. If there is a break in that connection from the top (Incident) to the bottom (Corrective Actions) there is generally a problem with the analysis.

The issue that prompted this article relates to how people go through the Root Cause Tree®. As the user gets down to the Root Cause level I begin hearing people making declarations, “We could fix this issue by labeling the medication better” and with that statement the team puts a positive checkmark by Labels NI. What is wrong with this statement and action? Nothing upon first glance if it is true that a better label could prevent recurrence.

Digging deeper, these types of thought processes are actually working in reverse of what we teach. We teach to look at the data on the SnapCharT®, read the definitions to determine if the data supports selecting Labels NI. Based on our teachings we should hear statements such as, “Do I have an evidence (on my SnapCharT®) that tells me that the labeling present at the time of the event contributed to this Causal Factor (and thereby to the Incident)?” Notice that one quote is a question and one is a statement and therein lies a key difference. As we work through the analysis we should be questioning our data versus the definitions and items in the Root Cause Tree® not stating how we could fix the issue. Once we have the Root Cause, we can then work on a Corrective Action to fix the Root Cause.

In conclusion if we choose the Corrective Action first followed by a cause that justifies that action, the investigative team has created a break in that “Specific Relationship” from top to bottom. That break is between the Causal Factor/Root Causes and the data collected on our SnapCharT®. Without data on the SnapCharT® to support the Root Causes you present to your management team, you put your analysis in question. Without belief in the analysis management will be less likely to provide you the resources you need to fix issues and improve performance.

If you would like more information on this or any topic relating to the use of TapRooT® in Healthcare feel free to contact me directly at or at (865) 539-2139.

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