Root Cause Analysis Instructor Lead Blog

What is the state of your lunch room?

August 8, 2009

I recently had a discussion with a behavioral expert.  This person is a PhD Psychologist who specializes in workplace safety.  He told me that he could tell more about an organization’s safety culture by looking at their break room than a whole day of site interviews.
Key things this person looks for:
Sloppy Sink?
Drab Walls?
Stuff on tables?
Decent [...]

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Getting information out of your head

August 3, 2009

David Allen’s book, Getting Things Done, is subtitled The Art of Stress-Free Productivity. He has a practical way or organizing work and life. Fast Company magazine refers to David as “the productivity guru.”
In Chapter 1 is a section called The Major Change: Getting It All Out of Your Head. David wrote, “The big difference between [...]

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Why Are Some Hospitals Better Than Others?

July 31, 2009

A USA Today article published earlier this month (‘Double failure’ at USA’s hospitals, dated July 9, 2009) discussed a Medicare analysis of U.S. hospitals which found that some hospitals have higher death rates and higher patient readmission rates than other hospitals.  “At 5.9% of hospitals, patients with pneumonia died at rates significantly higher than the [...]

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How Would You Like to Sit Next to a Bomb?

July 30, 2009

I was at a Safety Conference hosted by a group of Psychologists.  Now you can imagine the wide variety of insights to human behavior – it was an eye-opening experience in many ways.  One discussion by Dr. Tim Ludwig started out like this…  “What would you do if I had a bomb and placed it [...]

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What do you call it? Root Cause Analysis?

July 23, 2009

I have recently been challenged by a safety group about the Root Cause Analysis methodology.  Often Root Cause Analysis is perceived as the process by which the ‘single cause’ is found; what is the one thing that can be blamed for failure? 
This group of safety professionals was so frustrated with the term ‘Root Cause Analysis’ [...]

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Facilitation Doesn’t Always Require a Meeting

July 17, 2009

Most of the time people think of facilitating a root cause analysis as conducting a meeting.  People with first-hand information and various stakeholders get together for an investigation.  The facilitator is the person who leads that meeting.  There are specific things the facilitator can do to make the investigation more organized and clearer to arrive [...]

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The Diagram Changes the Discussion – Pole Injury

July 16, 2009

We recently began a meeting to perform a root cause analysis in which one of the participants felt that the discussion was pointless because we already knew the cause.  This happens often when, at first glance, there seems to be a simple clear cut cause for an incident.
In this situation a person had been distracted [...]

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Best Solutions Don’t Cost Too Much

July 14, 2009

When conducting a root cause analysis for a client it’s common for one of the employees to ask “What if we find the very best solution, but it costs too much.”  I always turn this question back to the clients and ask them for their thoughts.  Usually one of their coworkers quickly responds by saying [...]

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A Failure Mode is a Cause That Could Happen

July 10, 2009

Failure mode effects analysis, also known as FMEA, is a structured way to identify the different ways a system can fail.  It can be a very effective tool for identifying the highest risks for failure.  Prioritizing those risks provides direction on what action(s) should be taken, which makes FMEA an excellent tool for identifying and [...]

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Pull Lessons Learned From Your People

July 7, 2009

The intent of lessons learned is to review a particular situation and provide specifics on what to do and not to do the next time.  Lessons learned are written within companies to share what went well and what went wrong.  How the lessons learned are documented and distributed can affect their success.
In the particular case [...]

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