Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (US Army Medical Command)
Dana Rocha of US Army Medical Command shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during out Users Share Best Practices session. Watch her video below to learn how she has tailored her TapRooT® investigations so that they are the absolute most thorough they can be:
If you’re at work and don’t have time to watch the video, here’s her tip:
Hello, my name is Dana Rocha, I work for US Army Medical Command. With the help of the navy and the air force we in the army have put together a couple of different documents for people who haven’t been through the training to prepare them for facilitating an RCA as well as sitting on a RCA team. And what we did is we put together a couple of documents for “just in time training” for TapRooT® to help them facilitate and what your roles and responsibilities are on the team. We also put together an RCA trifold and what this is, is a root cause analysis for what event you’re looking at whether its an adverse outcome or sentinel event, near misses or you’re looking at something proactively. It doesn’t matter what you’re looking at, so we use it in different realms. We also put together some checklists. When you do your SnapCharT®, have you considered this? Have you considered that? Check the dates, check the times. Talk to people, and things like that and we found this to be very helpful. And we have done checklists for certain types of events that we find occur more frequently than others. When I say this, don’t freak, but wrong site surgeries do occur, we have retained foreign objects, all kinds of things that do happen, unanticipated deaths, so certain types of events we put together the most common things and asking the questions to make sure that we do a real thorough job when we do the analysis and the investigation so we found that to be very helpful.
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