March 25, 2021 | Mark Paradies

Bad Advice or Good Advice

Bad Advice to Stop Doing Root Cause Analysis

I read some bad advice in an on-line article. It said that you should do Apparent Cause Analysis on smaller incidents and precursor events and save root cause analysis for the “big incidents.”

First, what is Apparent Cause Analysis? Read this article about Apparent Cause Analysis in the nuclear industry…

The bad advice article said:

For example, an incident where a patient’s oxygen supply ran out but the pulse oximeter alarm caught it before harm was done would merit a quick, Apparent Cause Analysis to understand why the oxygen ran out. Just Do Its (observations of rules being broken) that have become a recurring theme should be bumped up into the Apparent Cause Analysis category as well.

Before I explain why this is bad advice, let’s tackle one more definition.

What is a Precursor Incident?

We wrote a whole article (actually several) about Precursor Incidents. Here’s one to get you started…

Now let’s look at the example mentioned above (the oxygen tank ran out).

What could have happened if no one responded to the pulse oximeter alarm? Could that happen? Has anyone ever failed to respond to an alarm in a hospital? Has anyone ever died because someone failed to respond to an alarm?

The answer is that someone could die (and people have died) because an oxygen tank ran out and no one responded to the alarm.

Therefore, this incident should have been categorized as a precursor to a fatality. This type of precursor incident deserves a root cause analysis.

Bad Advice

And that’s why the article’s advice is BAD ADVICE. Without good root cause analysis, the problems will probably remain in place until someone dies. It shouldn’t take a fatality or a serious injury to encourage people to improve performance.

Thus, management needs to err on the side of caution. If the incident could result in serious harm, it deserves a root cause analysis with effective corrective actions – not a quick and easy apparent cause analysis.

However, in the bad advice, there is a hint of good advice. The article wants people to perform simpler investigations of these precursor incidents. The question is … is that possible? Can a simpler root cause analysis yield good results?

We Wrote the Book on Simple Root Cause Analysis of Precursor Incidents

In 2015, we wrote the book on performing investigations using the essential tools for root cause analysis. The idea was to cut the amount of effort spent while still getting good results by using the essential root cause analysis techniques. What’s the name of the book? Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

How does the book simplify root cause analysis?

  1. It uses a simpler process (only five steps).
  2. It stops the investigation if further investigation is NOT worthwhile.
  3. It uses fewer techniques (just the essentials).
  4. If focuses only on the root causes (not the generic causes).
  5. It uses the Corrective Action Helper® Guide to speed up the development of effective corrective actions.

Let’s quickly look at the simplified process…

Both Processes

The seven-step process is on the right. It is for major accidents. The simple process is on the left (below too).

Simple Process

You can see the tools used in each step. Those are the essential tools. They include SnapCharT®, the Root Cause Tree®, and the Corrective Action Helper® Guide. All of these essential tools are computerized in the TapRooT® Software.

In 2.2, we make the decision (based on the information in our SnapCharT®) if there is potential for more learning or if we should stop (nothing more to learn).

Good Advice: Learn the Essential Root Cause Analysis Techniques

Would you like to learn more about this simplified yet effective way to use the TapRooT® Root Cause Analysis System for low-to-medium risk incidents? Then you should attend one of these courses…

2-Day TapRooT® Root Cause Analysis Course

This course teaches the simplified 5-step process and the essential techniques. Get more information by CLICKING HERE.

Virtual 3-Day TapRooT® Root Cause Analysis Course

The same topics as the 2-Day TapRooT® Course but taught in a Virtual 3-Day format. Read more about the course and it’s development HERE. Register for our Public Virtual 3-Day Root Cause Analysis Course being held on June 13-15 HERE.

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

Learn the essential techniques and the whole 7-step process and optional techniques in this 5-Day Training. Get more information HERE.

Don’t Listen to Bad Advice

You can’t afford to wait for fatalities or serious injuries before you start the improvement process. And ineffective investigations (Apparent Cause Analysis) won’t deliver effective fixes. You need to apply the essential root cause analysis tools to precursor incidents to develop effective fixes. Learn how at one of the courses above.

Categories
Courses & Training, Patient Safety & Healthcare, Root Cause Analysis Tips
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