Clik here to view.
Is Blame Built Into Your Root Cause System?
If you want to stop good root cause analysis, introduce blame into the process. In recent years, good analysts have fought to eliminate blame from root cause analysis. But there are still some root...
View ArticleClik here to view.
Winners and Losers in Healthcare’s Shift to Value-Based Payments
The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human...
View ArticleClik here to view.
Management System
Back in 1985, my boss suggested I (Mark Paradies) look at better ways to analyze and trend root causes. I already understood human factors (from training for my masters degree from the University of...
View ArticleClik here to view.
Remembering An Accident: Sayano-Shushenskaya Hydroelectric Dam
One of the world’s largest hydroelectric plants, Sayano-Shushenskaya Hydroelectric Dam, suffered a catastrophic failure On August 17, 2009, that lead to the death of 75 people, and the pollution of the...
View ArticleClik here to view.
What’s Wrong with Pharmaceutical Root Cause Analysis?
I was forwarded a copy of an interesting letter about Amarican and Canadian Standards Boards with Certifying Bodies rejecting pharmaceutical quality incident reports because of poor root cause...
View ArticleClik here to view.
TapRooT® Around the World: Bogota, Colombia
Here’s a peek into the recent 2-Day TapRooT® Root Cause Analysis Training Course in Bogota, Colombia, taught by TapRooT® Instructor Piedad Colmenares. In a 2-Day TapRooT® course, you will grasp how to...
View ArticleClik here to view.
Is “Wear and Tear” an Acceptable Equipment Root Cause?
In 2016, the Bureau of Safety and Environmental Enforcement (BSEE) expanded the SafeOCS reporting system to require the submission of off-shore well control equipment failure reports. The first annual...
View ArticleDoes Social Media Encourage Poor Root Cause Analysis?
Who doesn’t love a good online video? Videos can encourage interaction and make you think, but are they leading us down poor thought paths or compelling us to jump to conclusions? Asking ourselves this...
View ArticleMonday Accidents & Lessons Learned: “Brute Force” Compromises Assets
Fighting today’s cybercrime has become one in which businesses continually strive to stay ahead of the most recent evolution. Technology has forever changed the way we work, and the company culture...
View ArticleClik here to view.
What makes a great root cause system?
What makes a great root cause system? That’s a question that I started researching back in 1985. What would I say is the answer to that question 33 years later? Here are some of my best ideas… 1....
View Article
