December 9, 2019 | Mark Paradies

Hospital Patient Safety-Related Death – What is an adequate root cause analysis?

Patient Safety: Death at a Psychiatric Hospital

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I read an interesting article about a death at a psychiatric hospital. One of the main disputed points in the article was about root cause analysis and staffing. Was inadequate staffing the root cause of a suicide?

What is Adequate Staffing?

That’s a difficult question to answer. Staffing levels are always hard to evaluate, even for human factors professionals. In this case, it seems that the patient was supposed to be continually monitored (one on one supervision) but was not monitored. Thus, it seems if we counted the number of patients that required constant monitoring and the number of staff, the number of staff would have to be more than the number of patients that required continuous monitoring. How much more? That depends on what other jobs there are to do, allotment of time for breaks and meals, and rotation of staff members.

The article didn’t get into the granular details needed to perform this kind of evaluation.

Full Root Cause Analysis

The article did state:

“The company said after Ms. Greaves‘ death it undertook a full root cause analysis and implemented a number of measures, including the coroner‘s recommendation that signs should be put up requesting patients not to throw objects onto the floor.”

It seems that the suicidal patient picked up a discarded piece of cloth she found outside her room and used it to commit suicide.

Do you think a sign for other patients in a psychiatric hospital telling patients not to throw objects on the floor is an adequate corrective action? Where does it fit on the TapRooT® hierarchy of corrective actions/Safeguards?

Do you think having a new sign is an adequate defense of their root cause analysis?

Please leave your comments in the Comments section below.

Learn to Perform a Thorough and Credible Root Cause Analysis

What is a thorough and credible root cause analysis? See this LINK for an answer. The UK now requires root cause analysis with a systems approach and an emphasis on human factors. Thus, a great start for any systems-based root cause analysis with an emphasis on human factors would be a TapRooT® Root Cause Analysis.

Why TapRooT®? Because it was designed to be a systematic process with expert systems to help find the causes of human error. Want to find out more? See:

How can you get trained to use the TapRooT® System? Have a look at our training:

Then have a course at your facility or attend one of our public TapRooT® Courses.

Are you interested in a course specifically designed for people in the healthcare field? Then attend the TapRooT® Root Cause Analysis for Patient Safety Improvement Course being held on March 9-10 at the Horseshoe Bay Resort (near Austin, TX). For more information, see:

Here is the course outline:

Day 1 (8:00am to 5:00pm)

  • Class Introductions and TapRooT® Introduction
  • TapRooT® System Overview – What you will be learning
  • SnapCharT® Basics – Gathering Information
  • SnapCharT® Exercise – Practice
  • Causal Factors – Identifying the Error
  • Root Cause Tree® – Eliminating Blame
  • Root Cause Tree® Exercise – On Your Own
  • Corrective Actions – Developing Fixes

Day 2 (8:00am to 4:00pm)

  • Software Overview – Practicing the Techniques
  • Generic Causes – Optional Technique
  • Causal Factors – Additional Practice
  • Reporting – Management Presentation
  • Frequently Asked Questions
  • Final Exercise – Putting What You’ve Learned to Work

The course is being held as part of the 2020 Global TapRooT® Summit week.

To register for the Summit and the course, CLICK HERE.

To register for the course only, CLICK HERE.

nurses in root cause analysis class

Accidents, Patient Safety & Healthcare
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