Book 9: Improve Patient Safety with TapRooT® Root Cause Analysis
Patient safety and infection control are not optional. If the quality of patient care is your concern, you need to consider advanced root cause analysis–TapRooT®–to improve patient safety.
Depending on the study you read, somewhere between 60,000 and 200,000 people per year are killed or seriously harmed by medical mistakes—in occurrences such as wrong-site surgeries, misadministration of drugs, improper use of medical devices, and even simple things such as slips and falls.
Why doesn’t the medical community learn from its mistakes and prevent repeat incidents?
One of the reasons is that they have not adopted advanced root cause analysis. The TapRooT® Patient Safety Book Set provides healthcare professionals with knowledge of advanced root cause analysis: the TapRooT® System. The TapRooT® System provides a scientific method to find and fix the causes of human error and equipment failures. TapRooT® Root Cause Analysis can be used to reactively investigate and prevent repeat sentinel events or proactively to improve performance by finding and fixing a problem’s root causes before a medical error occurs.
How do healthcare organizations reduce the risk and financial burden of mistakes and errors that cause poor clinical and financial outcomes? Lives depend on TapRooT®’s world-class investigation, root cause analysis, and corrective action implementation processes. Learn more through the TapRooT® patient safety publications.
The TapRooT® philosophy is, Don’t let another sentinel event harm a patient. Learn how to use TapRooT® Root Cause Analysis to improve patient safety at your facility.
Book 9 of the ten-book TapRooT® Book Set is the medical book, “Improve Patient Safety with TapRooT® Root Cause Analysis,” and the medical dictionary, “TapRooT® Root Cause Tree® Patient Safety Dictionary.”
TapRooT®’s focus for the Patient Safety Book Set is to help the medical community learn from its mistakes and prevent repeat incidents.
The publications equip medical professionals with knowledge of advanced root cause analysis through the TapRooT® System.
The pocket-sized medical dictionary, “TapRooT® Root Cause Tree® Patient Safety Dictionary.” authored by Mark Paradies and Linda Unger, is for use in tandem with TapRooT®’s Root Cause Tree® (the Root Cause Tree® is part of the TapRooT® System for root cause analysis and problem investigation), providing definitions for each category on the tree. The definitions are in the form of questions and any “yes” answers apply to the causal factor or issue being analyzed. The dictionary is also a useful resource in helping settle debates between team members when using the Root Cause Tree®.
About the Authors
Mark Paradies and Ken Turnbull are the authors of “Improve Patient Safety with TapRooT® Root Cause Analysis.” Paradies has 38 years of experience in high-reliability organizations, process safety, incident investigation, and root cause analysis. His career began as a leader in Admiral Rickover’s Nuclear Navy, where he earned Engineer qualification. He worked for Dupont in the areas of human factors, process safety, and performance improvement management prior to starting System Improvements Inc. In 1993, after his mother suffered from a sentinel event, Paradies launched System Improvements’ initiative to improve patient safety. Turnbull began his career in fire safety engineering, industrial safety, and process safety in the chemical and oil industry. After retiring as Corporate Safety Manager for Texaco, where he had used the TapRooT® System, Turnbull became a TapRooT® Instructor. Since then, he has helped people around the world improve their root cause analysis and stop repeat problems, including training over 500 healthcare professionals to use TapRooT® to stop patient safety events. Turnbull’s wife is a retired nurse practitioner and his sister is an emergency medical physician—relationships that helped drive his interest in patient safety.
For details or inquiries about the TapRooT® System, call System Improvements Inc. at 865-539-2139, or contact us online at http://www.taproot.com/contact/. Learn more about TapRooT® at http://www.taproot.com.