August 6, 2008 | Mark Paradies

Is Their Root Cause Analysis Working???

Read this article from the Mid-Ulster Mail Newspaper and then ask … “What is the proof that their root cause analysis is working?

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Hospital Bug Claims More Lives
Published Date: 04 August 2008
By Stanley Campbell

THE C Difficile bug contributed towards eight more deaths in Northern Trust hospitals last month, according to the Trust.

A spokesperson today said the number reflected the high number of cases of C Diff at the start of the year.

A total of 19 new cases were identified in July – four fewer than the previous month.

The Department of Health said recently revealed that 86 people had died so far this year and all those deaths were linked to C-Diff.

Dr Peter Flanagan, the trust’s medical director, said: “Hospital medical staff are increasingly managing complex, often multiple, serious and chronic medical conditions.

“Modern antibiotics are very effective in treating many of these, resulting in a better outcome for patients.

“However, we have to balance prescribing with our understanding of the possible effects of long-term antibiotic use and the links with acquired infections such as C. difficile.

“This is increasingly an issue across health and social services for practitioners in all health care settings.

“The rate of new infections is falling. Using a root cause analysis approach for each new case we can say that there is considerably less transmission of the infection within Trust hospitals; that our infection prevention, control and isolation procedures are working.

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If they had eliminated cases of C-Diff – then they would have proof.

If they were drawing Process Behavior Charts and showing statistically significant declines (outside the process limits) on the Interval Process Behavior Chart for each hospital that had performed a root cause analysis and implemented corrective actions, then that would be proof.

If they were proactive and took the lessons learned from several hospitals and shared them across the Trust to have a statistically significant run of zero infections at MULTIPLE hospitals, then I would say they are really doing good root cause analysis.

But 23 cases one month and 19 the next? Hardly proof.

To read more about performance measures and using statistics to measure true improvement, see Chapter 5 of the new TapRooT® Book.

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