January 2, 2020 | Mark Paradies

Do Hospitals Need to Wait for “Never Events” to Improve?

I was reading about a man who had the wrong components installed during a knee replacement surgery. The article said the error was:

“…a ‘never event’ – one so serious it should never happen.”

The patient (pictured above) said:

“I was completely shocked, I was almost speechless,
which is most unusual for me … I said
‘how could anybody make a mistake like this’.”

The hospital’s Director of Nursing said:

“As with any serious incident or never event,
we carry out a full investigation to find out
how and why this occurred, to identify what
can be learnt from the incident and whether
any procedural changes are required. In the
meantime, immediate actions have been taken
including a review of our five steps to
safer surgery process.”

First, “review” (from the response above) is one of those NEVER corrective actions that we recommend you never use. What are the other “Re” NEVER corrective actions:

  • Re-train
  • Re-emphasize
  • Re-place (a part)
  • Re-mind
  • Re-evaluate
  • Re-qualify
  • Re-write
  • Re-peat

Why don’t we recommend these “Re” corrective actions? Find out in one of our TapRooT® Root Cause Analysis Courses.

Second, did they have to wait for this never event to discover weaknesses (which it seems they still haven’t discovered) in their systems?

The answer is “NO!”

They could have been proactive. They could have discovered and fixed the problems they have  BEFORE this poor man had the wrong component installed. They could have used TapRooT® proactively to strengthen their systems and Safeguards to stop human error.

Now, we have a new course for all types of industries (including healthcare) to help stop human errors both proactively and reactively. The name of the new course?

Stopping Human Error

The first of these courses is being held on March 9-10 at the Horseshoe Bay Resort near Austin, Texas. And if you are interested in stopping human error, we recommend that you register now!

If you want to:

  • Achieve excellent human performance.
  • Understand the methods you can apply to effectively stop major accidents and incidents by “stopping” human error.
  • Understand what are the most effective human performance improvement techniques and which ones are counterproductive (yes, some techniques really don’t work).

Then you should attend this course.

What will you learn?

  • The causes of human error
  • Human factors design best practices
  • Methods to find error likely situations
  • CHAP
  • Human Performance improvement Technology
  • Designing your human performance improvement program.

You will leave this course with a clear understanding of methods to improve human performance and a plan to apply those methods at your company to achieve great gains in safety, quality, or operational and maintenance performance (all of which depend on human performance).

Participants will also receive the new book, Stopping Human Error, a $99.95 value, as part of the course materials. in addition, participants will receive a certificate of completion and a 90-day subscription to TapRooT® VI Software, our dynamic cloud-based software that computerizes the TapRooT® Techniques.

Don’t wait. There are a limited number of seats in this course. Register TODAY!

Courses & Training, Human Performance, Patient Safety & Healthcare
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