March 26, 2019 | Marcus Miller

Vanderbilt Medication Error Update



The wrong medication error event at Vanderbilt Medical Center has turned even more tragic.  The nurse who made the error was charged with reckless homicide.  There is too much wrong with this story and it is becoming a major setback for patient safety.

Nurse charged in fatal drug-swap error pleads not guilty

Healthcare organizations depend on staff to report errors so those errors can be analyzed and fixed quickly to prevent further harm. When staff see a co-worker charged for reckless homicide because of an unintentional error, they will never feel comfortable reporting any other unintentional errors they make or witness knowing the outcome could mean jail time.  Patient safety risk will continue to escalate because errors will not be reported and fixed.  As the problems continue to build, those problems will line up exactly wrong one day resulting in patient harm.  Instead we need to work towards a culture that promotes reporting of errors so they can be analyzed and fixed to prevent harm and all the consequences that come with it.

TapRooT® is a comprehensive root cause analysis solution.  We train healthcare organization like Emory Healthcare and the Military Health System how to conduct investigations on all low, medium and high-risk incidents and audit findings.  We teach investigators how to collect and organize the data so every mistake, error, or equipment failure can be identified.  What truly makes TapRooT® best in class is that you take every error through our proprietary root cause analysis tree.  That allows you seize the opportunity to fix everything rather than just the main root cause you find with fishbones or 5 Whys.  The tree leads investigators through a series of yes or no questions designed to identify root causes in 7 main categories: Procedures, Training, Quality Control, Communications, Management Systems, Work Direction, and Human Factors.  The tree is designed to allow non-experts in any of these areas find the right root causes.

Then we teach how to create and implement corrective actions with validation and verification steps, so we have confidence and evidence that the corrective actions fixed the root causes as intended.

TapRooT® is a process and we supply tools and software for conducting investigations, root cause analysis, and corrective action implementation.  The software is an additional cost and is not necessary to use the TapRooT® process.  Any training we provide comes with a 90-day free software subscription so you can evaluate it before committing to purchase.

If you would like to discover if TapRooT® is the right continuous improvement process for your organization, you can contact me at to discuss.

Accidents, Courses & Training, Current Events, Implementation, Patient Safety & Healthcare, Root Cause Analysis, Safety
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