"Have a safe and skeptical New Year"? I love it, Bill! Be safe everyone and take care. Those of you in the Northeast US - stay home tonight! My speaking...
Rich, Thanks for your posting. There are many legitimate and "legitimate" reasons to get rid of people who were in charge of a fiasco. Here are a few. a.....
Accurate? Fair? Your comments? Thanks to "Steamshovel" for the heads up. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through...
Bill C., Over the years, you have made a lot of powerful statements about RCA. But none have been more powerful than your statement (below) that "an...
Bill Salot, There are three parts of a rational root cause analysis: 1.. Determination of Impact (Consequences and Significance). 2.. Determination of Factors...
Bill C, The 52-item list of RCA tools (below) is intimidating, and probably off-putting to beginners. The list needs to be worked around, shortened, or guided...
Bill Salot, Thanks for your continued interest in this topic. My grandfather told me that there is more than one way to skin a cat. (And my grandmother told...
Dr. Bill, May I add some info that Poka-Yoke (mistake proofing for zero defects / foolproofing) is not an analytical tool and not design to determine the root...
Hello Dr. Bill, May I add this tool P-M Analysis, where P stands for Physical / Phenomenon, M stands for Mechanism and 4 Ms (Man, Machine, Method, Materials) ...
Rolly, Again, you are absolutely correct. Certain rooticians have been using Poka-Yoke ideas in root cause analysis. Some rooticians have found that Poka-Yoke...
Bill, Would you please expand on your parting statement: "OBTW: We had two medical fatalities here in Connecticut in which a Poka-Yoke application was an...
Rolly, Would you like to enter it yourself or would you like me to do it? Question: Can you give a real life example of a single cause problem? Thanks for the...
Can you clarify? This implies that the attempt to error-proof was a CAUSE of the fatalities? "OBTW: We had two medical fatalities here in Connecticut in which...
Bill C., I appreciate the effort you have put into starting what promises to be a large data base. The information will enable further and better discussions...
Bruce, Here's the all-time greatest web site on Mistake Proofing. http://www.mistakeproofing.com/ Take care, Bill Corcoran Mission: Saving lives, pain, assets,...
Yes, Bruce and Cindy, it's true. Solutions cause problems. In order to "mistake-proof" the oxygen (O-2) and nitrous oxide (NO) connections they put two prongs...
Bill, Thanks. Here's the latest version. I'm still looking for info on TOPS and CAMP, which were used in different Honeywell facilities. Take care, Bill...
Interesting. This sounds like the result of the "Fix" for a patient gas administration death in CT several years ago. Possible missed opportunities or fixes,...
To be honest with you it doesn't seem to me that design or selection of an inadequately robust connection would meet "mistake proofing" criteria. At least I...
Jack, Thanks. Your posting prompted me to think about reversibility. Those of us who have operated in a high hazard industry, perhaps all of us, are well...
There are several techniques available to insure that the correct medical gas is delivered. For example: + Color coding (oxygen is green, nitrous oxide is...
Bill C., Would it be fair to lump "reversibility" into the "barriers" category, and to treat it as such? Example: Failure to reverse a bad decision, that has...
Matt, I am interested in discussing this with you, or replying to you via E-Mail or phone. I won't take much of your time. But I don't know how. Please...
Thank you, Bill! Good response. I was in SRO license class at CT Yankee when the pool seal failed. And who was the refueling modifications trainer for this...
Jack, I'd be happy to talk to you. The healthcare industry has a lot to learn from other high-consequence industries. As part of my consulting practice I do...
This occurred within months of my fights with the Keene police….about the arrest of my cerebral palsy buddy, with me being told Tom could have had a pistol ...
I'm looking for a different point of view. Their are lots of ways of looking at chains of factors. Here's one. What's wrong with this picture? OBTW: Consider...
Jack, Thanks ever so much. See the new one below my signature block. What's wrong with the new one? Take care, Bill Corcoran Mission: Saving lives, pain,...
Bill et al, 1. "Proximity" is not only unexplained, it is not sufficient to constrain an investigation to the (presumed) immediate proximity (e.g., the real...
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