This happened not too long ago at a US national lab and in Rhode Island. Does your organization use the term "mix-up?" Is "mix-up" in your safety and quality...
What do you conclude from this article? What is the practice at your facility? ___________________________________________________________________ July 2,...
To All: I conclude the research is accurate and cite these root cause blogs as prima facia evidence supporting the researcher's conclusions. Sincerely, Mark ...
Scroll down for the story. What's wrong with this picture? What are the lines of inquiry for the defense? What are the lines of inquiry for the prosecution? ...
<http://www.meait.com/> meait Logo July 4, 2008 Jobs - July 2008 <http://www.meait.com/general/login.aspx> login here to verify & update your resume. Featured...
We include discussion on the intended use of information and have a firm standard that NO names are used in the final report; identification is by position or...
Enter your vote today! A new poll has been created for the Root_Cause_State_of_the_Practice group: In my organization root cause analysis interviewers o do...
Root_Cause_State_of_t...
Root_Cause_State_of_t...
Jul 7, 2008 4:32 pm
5096
Steve, Thanks. Do you know what the rule is designed to accomplish? Is it successful? I've seen places that have a rule that all names are used in the report...
Well, here is my deal, You can try to hide whatever you want, but you will generally fail. You can try to cover up whatever you want, but expect failure....
Jack Stanford
jack.stanford@...
Jul 7, 2008 11:06 pm
5098
Doug, Great example. There are many others, e.g., aspirin, martinis, democracy... Here is an example of an inverse dose-response relationship. ...
This is worth a thoughtful read, for the technical issues, the transparency and leadership commitment, and the application of root cause and safe culture...
Bill C, The link did not work for me. If it had, I would have voted for the fourth bullet, not because I believe in it, but because that is the way it is done...
Bill Salot and all, At the bottom of every e-mail from this group is a link to polls. Click on it to go to the polls section. (There are other useful links as...
Cindy, Thanks ever so much. It is indeed refreshing to see openness, transparency, and candor. It would be even more refreshing if BIDMC would tell us: What...
Well, I E-Mailed a member of this group who makes a living doing RCAs on this sort of thing. He said that the right practice is to write on the correct limb,...
Jack Stanford
jack.stanford@...
Jul 8, 2008 5:08 pm
5104
Bridget Ann, Please pass this to Chairman Rosenker. Please think about the earlier, better, cheaper, safer ways that these problems could have been found. Did...
Bill C, I can see how your advice, including the "property of the Universe", could be confusing to someone not familiar with "factor trees". What is not...
Well, given my reactor engineering background, I am shocked that the University of Colorado had no procedures in place for routine handling of Plutonium or...
jack.stanford@...
Jul 11, 2008 4:03 pm
5109
Ah - your comments bring to mind some old memories from Rocky Flats... At one point in time, "they" determined that if the ventilation system ever flooded,...
Maybe we can use this to develop corrective actions? We seem to have a procedure use and adherence problem. We use enforcement and persuasion using graphic...
I think everyone in my business has a procedure use and adherence problem...I am very interested in this string. This problem seems to ebb and flow with...
Mike et al: I’m jumping into this one in mid-stream, so please forgive any redundancy that I’ve not yet read. However, reading the following in the...
Hi Larry I am still kicking (not ticking yet). Its very good to hear from you. Mike lbdurham <LBDurham@...> wrote: Mike et al: I’m jumping into this...
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