There are many factors that are stranger than fiction in this one. But there are many RCA lessons to be learned. Please let us know what you think can be...
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Root_Cause_State_of_t...
Sep 1, 2008 3:40 pm
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This file contains my comments. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want...
Causation of Extent Introduction The purpose of this discussion is to explain the concept of causation of extent so that it can be specified as an attribute of...
Colleague, I just recovered from a computer failure that could have been a lot worse. I was on vacation on the other coast when my laptop refused to boot-up. ...
Bill C, Did you mean to cut off the article in mid-sentence? I think defining the expression "safety culture" is a worthy issue. In locations where I have...
I believe that: Culture is learned by individuals within an organization and shaped by individuals within the organization. The culture is perpetuated by the...
Bill Salot, The left off word is "confusion." Sorry. If you know what "safety" is and if you know what "culture" is, as most of us would testify under...
Bill Salot and all, I have finished the comments on the b-words. Please send comments on the c-words. Take care, Bill Corcoran Mission: Saving lives,...
This really makes the case for designing your performance measurements carefully. I've said it many times before, but what you measure and, therefore, reward,...
The reward system not only encouraged the misapplication of the antibiotics but also encouraged the system to not record the reason why the antibiotics were...
Hi all, Recently, as part of an RCA training exercise, the group that I was working with came up with a series of "lack of" factors and a final "lack of" root...
Dave, The "lack of" statement is just another way of saying something was missing (such as a missing barrier or control - could be physical or admin). The...
Gentlemen, 1. Causes (causal factors) have to be specific behaviors or conditions. A legitimate causal factor would be something like "training did not...
I find it hard to think of an example where "lack of" would be a root cause. Most always, subjecting a "lack of" to a "why" analysis will yield an answer...and...
I appreciate the responses provided by the "Three Bills." We are conducting a lengthy root cause analysis on why our safety review process allowed an activity...
Bruce Hart
avsafety@...
Sep 14, 2008 10:38 am
5181
Bill Wightkin, What do you have in mind when you say "root cause?" There are nine definitions in The Rooticians' Dictionary at ...
Glen, Â Once again your folk wisdom shines through. Â Your SIL's organization is not the only one that hides problems and applauds failures (as "good...
Hi All, Â Thanks for your input. I understand what you are saying but I think I am miscommunicating both the situation and my question. That's my fault. In my...
Found this today: What are the LOIs? What are the alternatives? http://www.foxnews.com/story/0,2933,422462,00.html WASHINGTON * U.S. hospitals and long-term...
Dave, Â What would the consequences been if the operator had not successfully removed her hand? Take care, Â Bill Corcoran Mission: Saving lives, pain,...
The "if the bolt hadn't broken" comment concerns me. That comment strikes me as avoiding the issue altogether. We can all be sure if it wasn't this one it was...
Bill,  If she had not successfully removed her hand she could have suffered a very serious injury. Had any part of her fingers or hand been caught between...
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