February 20, 2023 | Mark Paradies

Do Hospitals Need to Wait for “Never Events” to Improve Human Performance?


Man Left Speechless After a Never Event

I read about a man who had the wrong components installed during a knee replacement surgery. The article said the error was:

“…a ‘never event’ – one so serious it should never happen.”

The patient (pictured above) said:

“I was completely shocked; I was almost speechless,
which is most unusual for me … I said
‘how could anybody make a mistake like this.'”

The hospital’s Director of Nursing said:

“As with any serious incident or never event,
we carry out a full investigation to find out
how and why this occurred, to identify what
can be learnt from the incident and whether
any procedural changes are required. In the
meantime, immediate actions have been taken
including a review of our five steps to
safer surgery process.”

Review is a NEVER Corrective Action

First, “review” (from the response above) is one of those NEVER corrective actions that we recommend you NEVER use. What are the other “Re” NEVER corrective actions:

  • Re-train
  • Re-emphasize
  • Re-place (a part)
  • Re-mind
  • Re-evaluate
  • Re-qualify
  • Re-write
  • Re-peat

Why don’t we recommend these “Re” corrective actions? Find out in one of our TapRooT® Root Cause Analysis Courses.

Did the Hospital Have to Wait To Learn Their Lesson?

Second, did the hospital have to wait for this never event to discover the weaknesses (which it seems they still haven’t discovered) in their systems?

The answer is “NO!” they didn’t have to wait. And you don’t either.

The hospital (or any facility) could be proactive. They could discover and fix the problems BEFORE this poor man had the wrong component installed. They could use TapRooT® RCA proactively to strengthen their systems and Safeguards to stop human error. (See info about a course that teaches you to do this HERE.)

Learn to Stop Human Errors


We have a course for all types of industries (not just healthcare) to help stop human errors both proactively and reactively. What is the name of the course?

Stopping Human Error

When is the next course? April 24-25 at the Margaritaville Lake Resort near Houston, Texas. And if you are interested in stopping human error, we recommend registering now!

If you want to:

  • Achieve excellent human performance.
  • Understand the methods you can apply to effectively stop major accidents and incidents by “stopping” human error.
  • Understand what the most effective human performance improvement techniques and which ones are counterproductive (yes, some techniques don’t work) are.

Then you should attend this course.

What will you learn?

  • The causes of human error
  • Human factors design best practices
  • Methods to find error-likely situations
  • CHAP
  • Human Performance improvement Technology
  • Designing your human performance improvement program.

See the complete course outline HERE.

You will leave this course with a clear understanding of methods to improve human performance and a plan to apply those methods at your company to achieve great gains in safety, quality, or operational and maintenance performance (all of which depend on human performance).

Participants will also receive the new book, Stopping Human Error, a $99.95 value, as part of the course materials. Participants will receive a certificate of completion and a 90-day subscription to TapRooT® VI Software, our dynamic cloud-based software that computerizes the TapRooT® Techniques.

Don’t wait. There are a limited number of seats in this course. Register TODAY!

2023 Global TapRooT® Summit

But wait! There’s MORE!

On April 26-28, at the same location, is the Global TapRooT® Summit.

The Summit includes a Best Practice Sharing Track about Improving Human Performance.

RaDonda Vaught at the trial.

Also, one of the Keynote Speakers is RaDonda Vaught, who was charged with criminally negligent homicide and abuse of an impaired adult after making a mistake. Hear her story and learn why proactive improvement is so important.

Attend both the Summit and the Stopping Human Error Course and SAVE $300. CLICK HERE to register for both. See the table below for additional potential savings.

Summit Discounts
Courses & Training, Human Performance, Patient Safety & Healthcare
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