May 21, 2019 | Mark Paradies

Patient Safety Root Cause Analysis

Patient Safety Root Cause Analysis

Is root cause analysis different for patient safety events (sentinel events)?

Do doctors and nurses make mistakes for different reasons than other human beings?

At System Improvements, we see the application of root cause analysis at all different kinds of companies all around the world. We see it used to improve:

  • industrial safety,
  • process safety,
  • quality,
  • equipment reliability,
  • operational excellence,
  • cost,
  • schedule performance, and
  • even patient safety.

What we have observed is that people make mistakes for the same kind of reasons in different industries and professions doing different kinds of work and the reasons are the same (or very similar).

Thus, a world-class root cause analysis tool (TapRooT®) can be used in any of the above situations to find and fix the root causes of problems and improve performance. This includes patient safety-related sentinel events at hospitals.

To make it easier for healthcare professionals to apply TapRooT® Root Cause Analysis in the healthcare setting, we wrote a book to explain how to apply TapRooT® specifically to Patient Safety Events.

The book is titled: Improving Patient Safety with TapRooT® Root Cause Analysis.

The book is available at this link:

What’s in the book? Here is the Table of Contents…


Chapter 1: The TapRoot® 7-Step Process for Patient Safety

–  Plan Phase
–  Investigate Phase
–  Analysis Phase – Define Causal Factors
–  Analysis Phase – Root Causes
–  Analysis Phase – Generic Causes
–  Develop Fixes
–  Present/Report for Approval

Chapter 2: Step 1: The Plan

–  Define the Incident
–  Plan the Investigation
–  Planning using SnapCharT®
–  What should your plan look like?

Chapter 3: Determine What Happened

–  Add facts to your SnapCharT®
–  Patient Safety SnapCharT® example

Chapter 4: Define Causal Factors

–  What is a Causal Factor?
–  Categories of Safeguards
–  Case Study Causal Factor example
–  Testing Causal Factors
–  Adding Causal Factors to a SnapCharT®
–  Why defining a Causal Factor is important

Chapter 5: Analyze Each Causal Factor’s Root Causes

–  Root Cause Analysis

Chapter 6: Analyze Each Root Cause’s Generic Causes

–  Generic Cause Analysis

Chapter 7: Develop Fixes

–  What’s wrong with common fixes?
–  Developing Fixes by creating or strengthening Safeguards
–  Corrective Action Best Practices
–  Developing fixes using TapRooT®
–  Using the Corrective Action Helper® Guide/Module
–  Checking your Corrective Actions – SMARTER
–  Complete corrective action process
–  An example of an effective fix

Chapter 8: Present/Report for Approval

–  Show management what happened
–  Show management why it happened
–  What can be done to keep it from happening again
–  A report for the Joint Commission

Chapter 9: The Whole Process Reviewed


Get Trained to Find the Real Root Causes of Patient Safety Events

When an where can you get trained? For the special TapRooT® Root Cause Analysis for Patient Safety Improvement Training see:

The course is being held on March 9-10, 2020, at the Horseshoe Bay Resort near Austin, Texas. Get more information about the 2020 Global TapRooT® Summit by CLICKING HERE.

Patient Safety & Healthcare, Root Cause Analysis
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