I have someone who informaed someone they were not wearing proper PPE in the work area and asked them to put it on, but did not report it. When asked why they...
MessageWe recently received permission to use a case history of ours in an anonymous format. I provided you all an RCA a while back on a Medication Near Miss...
Look deeper into what reinforcement is given for reporting PPE violations. What are the positive and negative consequences to reporting? What feedback does...
Bob, What would you say are the similarities and differrences between this approach and using Six-Sigma? I'm guessing that a number of companies would apply...
Hi Terry As I explained and apologized to Bill, I meant to post this on a healthcare site but inadvertently did so here. Nonetheless, your question is valid. ...
Bob, I'd guessed that your approach was not as time consuming, and not as rigorous as a Six-Sigma approach. It appears that the focus of the effort was to...
Hi Terry I understand and can appreciate the rigorous process associated with Six Sigma. We used this cursory tool not to consider it as a form of, or...
My 33 year seasoned opinion - all too close to the norm. An interesting analogy in the reactor world is the intelligent application of probabilistic risk...
Here is a quick and dirty analysis I did using Bob Latino's PROACT. The PPT slide is easier to read at 150% zoom or in "Slideshow" mode. I await your comments....
A different news story on the same event. It doesn't change much. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf Circle ...
Here's a third story on the same event. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 Voice...
Tish, ((sorry can’t remember if I posted this already)) (I apologize in advance if I am using harsh language –I don’t at all mean this to be a attack on...
Michael, That may be your experience with PRA, but not mine. What makes more sense; to treat everything the same or to assess the threats that pose the...
Terry, So you got any highly professional and highly educated outsiders on that PRA panel, who could stand up for themselves –or are they just industry...
MessageBob, Thanks for the analysis. I have two minor issues. 1.. I did not see any analysis of what influenced the bad draws. There is a remote chance that it...
Terry, I agree with your advice. My hunch is that there is a disconnect between what management says it wants and what it accepts as the norm. Take care, Bill...
MessageHi Bill C. I think there is a misunderstanding as to the the purpose of this Opportunity Analysis (OA), at least as we use it. It would appear that...
Sandy, You'd think they would run the machine on a dosimeter with a simulated patient at least once to confirm the setting. I would like to bring root cause...
The following applies to all root cause-effect trees 1.. A tree is no better than the rules used to make it. 2.. A tree is no better than the evidence behind...
4. A tree is no better than the facilitator's ability to enforce the rules, properly apply the evidence and effectively manage the potential bias and ...
Bob L., As an outsider to all things medical, am I free to ask dumb questions about your example? Example recap: 1. The first step of your "opportunity...
MessageHi Bill S. Thanks for the comments. Before I respond, I want to reiterate that this analysis was posted on this forum in error. It was intended for a...
Bill C. and Bob L., 5. A tree is no better than the role it is intended to play. What should be the primary role of trees in the RCA of major problems? Is the...
Well, Bob L., I don't intend to prolong this. I'll sign off with a pointed comment on each of the two title pages: 1. On the "Blood Drawing Process" analysis,...
MessageHi Bill S. Because I explained that they were both "examples". The Blood Draw one was used with anonymity of the real client. The HCP one is using...
Mike, We actually do have outsiders review the PRA model and how it was constructed at my facility. The purpose of our internal expert panel is different in...
Terry and Mike, One of the drawbacks of PRA is that it only considers what has been put into it. The worst PRA failure of recent years was its failure at...
Bill S., Thanks. I recommend that people at least do #6 on the second coming of the event. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC...
Terry, I am putting you on the spot-and I don't think it is fair of me ---but. 1) Does the NRC have outside the nuclear industry experts on the NRC PRA panel? ...
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