October 31, 2023 | Mark Paradies

Repeat Problems


Does Your Company Experience Repeat Problems?

If you perform an effective root cause analysis of an incident, you should be able to develop effective corrective actions that will prevent the incident from reoccurring. That should prevent future repeat problems.

If your company has repeat problems, that’s an indication of ineffective root cause analysis or ineffective corrective actions.

TapRooT® Root Cause Analysis of Repeat Problems

When you have a repeat problem and investigate the incident using the TapRooT® System, you should find a Causal Factor that leads you to the Management System Basic Cause Category and the Corrective Action Near Root Cause (shown below)

Corrective Action Near Root Causes that could lead to repeat problems
© 2015 by System Improvements, Duplication Prohibited.
Used by Permission.

If your previous corrective actions failed to prevent a repeat incident, there are three potential root causes:

  1. The corrective actions need improvement.
  2. The corrective actions previously recommended have not been implemented.
  3. You didn’t identify generic causes using your trending system (trending needs improvement).

If you are having repeat problems, you should be identifying one or more of these root causes.

What does the TapRooT® Corrective Action Helper® Guide have to say about fixing these problems?

Corrective Action Helper® Guide

You can find the answers on pages 117-122 of the guide (too much information to provide here). A quick summary of the recommendations includes.

  1. Perform better root cause analysis and develop more effective corrective actions.
  2. Implement the corrective actions in a timely manner.
  3. Improve your trending and the use of trends to identify Generic Causes.

Of course, we teach these things in our TapRooT® Courses.

Example of Repeat Failures (Repeat Problems)

In October of 2023, The Joint Commission published a Sentinel Event Alert #68 titled Updated Surgical Fire Prevention for the 21st Century. Why was this alert called an “updated?” Because in June of 2003 (twenty years earlier), they published Sentinel Event Alert #29 titled Preventing Surgical Fires.

Read the two documents at the links above. You will find they are very similar. Here is my question:

Why didn’t the first alert stop the problem of surgical fires?

Did the corrective actions need improvement?

Did hospitals fail to implement the corrective actions?

Did it really take 20 years of repeat incidents to identify the trend?

Also, shouldn’t any hospital with a previous surgical fire have performed a root cause analysis and implemented effective corrective actions?

To understand why there are so many repeat failures (repeat problems) at hospitals, you could read the article we published on October 3, 2023:

Why Does Healthcare Root Cause Analysis Fail?

Healthcare Root Cause Analysis

To summarize the three major points in the article, the problems with healthcare investigations and root cause analyses include:

  1. Blame
  2. Lack of Time/Support
  3. Poor Root Cause Analysis Tools, Improper Use of the Tools, and Insufficient Training of Investigators/Facilitators.

The article suggests ways to fix all of these problems. Until they are fixed, I expect more repeat problems in the healthcare industry and, perhaps, another Sentinel Event Alert about surgical fires … perhaps in 2043. Because when you don’t correct the real root causes of problems, you surely will see them repeat.

Improve Your Root Cause Analysis to Prevent Repeat Problems

If your company experiences repeat problems, you may need to improve your root cause analysis. Here are three suggestions to consider…

Take Advanced Root Cause Analysis Training

First, if you haven’t attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, attend one NOW! See the schedule for upcoming public courses HERE. Or schedule training at your site by CONTACTING US.

TapRooT® Course
Exercise at a 5-Day TapRooT® Course

We also sponsor other types of advanced training in our pre-Summit courses (on April 29-30 at the Horseshoe Bay Resort near Austin, Texas). These courses include:

Pick one and then see more information about the Summit below.

Grade Your Investigations

Grade Your Investigations

To improve performance, investigators/facilitators need feedback. That’s why we developed a systematic process for measuring (grading) the effectiveness of investigations and included it in the TapRooT® Software.

Want to learn more about grading investigations? Read THIS ARTICLE.

Attend the TapRooT® Summit

Do you want to learn incident investigation and root cause analysis best practices from around the world? Then, you should plan to attend the 2024 Global TapRooT® Summit being held on May 1-3 at the Horseshoe Bay Resort near Austin, Texas.

Summit Breakout Session
Summit Breakout Session

In addition to the great Keynote Speakers, there are seven Best Practice Tracks:

Each track has nine breakout sessions. Click on the links above for details about each track.

Before the Summit, there are 11 advanced pre-Summit Courses to choose from. CLICK HERE for more information.

See the matrix below for potential discounts when you attend both a pre-Summit Course and the Summit or bring a team of three or more people to the Summit…

2024 discounts SAVE

Don’t Wait

You need to prevent repeat problems. Start implementing the suggestions above TODAY!

Patient Safety & Healthcare, Root Cause Analysis Tips
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