I uploaded "The Firebird Forum" Vol. 7, No. 5. to http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice_II/ It deals with what to do after the Root...
Dr. Bill C stated "OBTW: At the beginning of this thread I asked if anyone's organization trended mix-ups. The silence has been deafening. Do I conclude that...
Terry, Thanks ever so much, Terry. I thought you'd never ask. :<) First let's deal with near misses. Every near miss is also another type of event. A pure near...
Ahhhh.... In looking at the database tables, your event types are not clearly described. In order to trend consistently, people need to understand the...
Terry, 1. You are welcome to post your own definitions/descriptions of the event types. 2. Do you suspect that some organizations do not want to know how...
Terry The point you make--that correct categorization is crucial--deserves emphasis. Variation in assignment of labels or the "coding problem" bedevils all...
Hi Whilst we may be ahead in some things, we are far behind in others - I suppose you could call it natural variation. As far as I am aware we ( my hospital )...
Our experience is that lessons learned presentations are the least effective corrective actions. We issue about 30 electronic lessons learned a year, and...
Dan, Thanks for your meaty response. I don't know where to start. Let's start with lessons to be learned presentations. I don't doubt that they are ineffective...
Bill, et al, One approach that I have seen work well: have the employee(s) responsible for the event give the presentation to their peers. The peers seem...
Jack, It's good to hear from you. I like your idea. In fact, I covered it in my latest issue of "The Firebird Forum," which should be in your e-mail inbox. How...
Bill C., I'll jump in with some comments embedded below: Bill Salot ... From: Dr. Bill Corcoran [mailto:firebird.one@...] Sent: Monday, May 03, 2004...
Bill Salot, Your posts are always thought provoking. Do you recall the play, "Teahouse of the August Moon?" I love the servant boy's discourse on the benefits...
Bill C., You out-thought-provoke me every time. I never experienced "Teahouse of the August Moon", so I don't know what the servant boy said. 1. Sure, start a...
We have a section on Methods and Tools at http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/ METHODS%20AND%20TOOLS/ I will be starting a...
1. I do visit that section. 2. My favorite two tools are the Comparative TimeLine and the Why Staircase Trees, but I also use the Missed Opportunity Matrix. 3....
Lessons Learned are distributed and read electronically, to Operations Personnel. The LL's are targeted to subgroups within the department as appropriate. If...
Does your organization have any "three strikes" rules? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts 21 Broadleaf Circle ...
Do you have any insights as to why these lessons to be learned reports did not result in changed behaviors? In other words, what is it about these reports that...
For those who have discussed medical issues on these forums, here is a link lifted from Mark Paradies' latest TapRoot e-Newsletter. PATIENT SAFETY LINKS People...
On that basis, I would also like to provide such good and free healthcare links at: http://www.reliability.com/healthcare/healthcare_links.htm Good reading! ...
Go to http://www.qualityhealthcare.org/IHI/Topics/Improvement/ImprovementMethods/Tools/InterviewGuideUsingtheinterviewasasourceofdatainformationandlearning.htm...
No. If we determine that the company we've hired is indifferent regarding worker safety all you get is one strike and we do a lot to figure out how we let a...
Bill C., 1 - Since you asked, I went ahead and visited the "Methods and Tools" section at your web site. Yes, I've been there before, but I must admit my...
wjsalot
wjsalot@...
May 9, 2004 6:16 pm
1584
Bill and others, would love for you to attach a copy of your Why Staircase Tree (or any other interesting tool examples) Helen ... Bill C., 1 - Since you...
Bill Salot, Thanks for the endorsement of the Why Staircase Trees. I, too, find them valuable for understanding the chains of influence for a particular...
Helen, To see a Why Staircase Tree download the last file in the files section folder called "Root Cause Analysis Reports." I look forward to your comments and...
Colleague, I am looking for a conduct of operations document for a non-nuclear power plant, e.g., coal and/or oil. What I have in mind is a document from the...
If you think that either a steel fabrication plant or a cast iron pipe manufacturing facility would work, I'll ask my son-in-law or my son's father-in-law,...
Larry, Thanks ever so much. I think that the generic principles of good operation would apply. If they have something that they would be willing to share,...
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