Some of you must be attending regular root cause analysis at your respective facilities and I’m sure that you can share some fantastic war-stories, finger pointing, blame anything and everything except for the real ROOT CAUSE of course!

I have been involved in pre-RCA, RCA and FMEA’s at multiple facilities and services over the past 20+ years in Healthcare and can say with great confidence that frequently the REAL root cause is ignored and blame is placed on its smaller sibling called TRAINING with little attention spend on big cousin BEHAVIOR.

We really should be doing a root cause on the root cause analysis process!

What should we do know… continue to fake RCA’s or actually dig deeper and start addressing systems issues by starting an analysis of risk exposure and mitigation. Not very sexy to work on prevention and mitigation however in the long run much less expensive and it might actually prevent an injury or illness…..what a concept.

Recently, I had the fortune to listen to a passionate, energetic bulky Lawyer/Engineer who told a story about safety using just three dice…. It was impact full and drove a point home in a very visual manner. Every patient care process should have minimally three individual/independent failure points before one can say that the process is designed with safety in mind. Even with a three dice process, there’s a real need for constant vigilance, surveillance and validation of the actual process to minimize impact!

Prevention is the name of the game… it’s not a question if you have the time to do it, you need to make time to do it!


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