October 1, 2010 | Mark Paradies

Seattle Children’s Hospital has Multiple Sentinel Events – Is Root Cause Analysis Working?

Here’s the video of the press conference:


The Seattle PI reported that the hospital is having a day long safety stand down and is having and independent root cause analysis performed.

My question is why past root cause analyses haven’t prevented these accidents. Also, why didn’t proactive audits, assessments, and observations prevent these accidents?

This is hard to judge from a distance. Are the root cause analyses being performed effective? We could say they the root cause analysis and corrective actions were effective if the problems stopped. It would be interesting to see a SnapCharT® of the incidents, a Safeguard Analysis including what Safeguards failed and which Safeguards worked. Then I would like to see each of the Causal Factors and how they would be taken through the Root Cause Tree®. Finally, I would compare their corrective actions to those in the Corrective Action helper® Module.

Without a thorough analysis, determining if this hospital is really solving the system problems is impossible.

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