New TapRooT® Publications: Improving Patient Safety Through Advanced Root Cause Analysis

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How do healthcare organizations reduce the risk and financial burden of mistakes and errors that cause poor clinical and financial outcomes? Lives depend on TapRooT®'s world-class investigation, root cause analysis, and corrective action implementation processes. Learn more through the new TapRooT® patient safety publications.

Patient safety and infection control are not optional. If the quality of patient care is your concern, you need to consider advanced root cause analysis–TapRooT®–to improve patient safety.

System Improvements Inc. is pleased to announce the publication of its new medical book, "Improve Patient Safety with TapRooT® Root Cause Analysis," and medical dictionary, "TapRooT® Root Cause Tree® Patient Safety Dictionary." 

A comprehensive study by researchers at John Hopkins University has found that medical mistakes are now responsible for more deaths in the U.S. each year than accidents, respiratory disease, and strokes. The study estimates that more than a quarter million people die annually due to errors made during medical procedures. The statistic does not include other sentinel events that do not result in death. Among the errors are wrong site surgeries, misadministration of drugs, improper use of medical devices, and seemingly ordinary events such as slips and falls.

TapRooT®'s focus is on helping the medical community learn from its mistakes and prevent repeat incidents. The new publications equip medical professionals with knowledge of advanced root cause analysis through the TapRooT® System. The TapRooT® System provides a scientific method to find and fix the causes of human error and equipment failures. TapRooT® Root Cause Analysis can be used to reactively investigate and prevent repeat sentinel events or proactively to improve performance by finding and fixing a problem's root cause before a medical mistake occurs. 

Mark Paradies and Ken Turnbull are the authors of "Improve Patient Safety with TapRooT® Root Cause Analysis." Paradies has 38 years of experience in high reliability organizations, process safety, incident investigation, and root cause analysis. His career began as a leader in Admiral Rickover's Nuclear Navy, where he earned Engineer qualification. He worked for Dupont in the areas of human factors, process safety, and performance improvement management prior to starting System Improvements Inc. In 1993, after his mother suffered from a sentinel event, Paradies launched System Improvements' initiative to improve patient safety. Turnbull began his career in fire safety engineering, industrial safety, and process safety in the chemical and oil industry. After retiring as Corporate Safety Manager for Texaco, where he had used the TapRooT® System, Turnbull became a TapRooT® Instructor. Since then, he has helped people around the world improve their root cause analysis and stop repeat problems, including training over 500 healthcare professionals to use TapRooT® to stop patient safety events. Turnbull's wife is a retired nurse practitioner and his sister is an emergency medical physician—relationships which helped drive his interest in patient safety. 

The pocket-sized medical dictionary, "TapRooT® Root Cause Tree® Patient Safety Dictionary." authored by Mark Paradies and Linda Unger, is for use in tandem with TapRooT®'s Root Cause Tree® (the Root Cause Tree® is part of the TapRooT® System for root cause analysis and problem investigation), providing definitions for each category on the tree. The definitions are in the form of questions and any "yes" answers apply to the causal factor or issue being analyzed. The dictionary is also a useful resource in helping settle debates between team members when using the Root Cause Tree®. 

For details or inquiries about the TapRooT® System, call System Improvements Inc. at 865-539-2139, or contact us online at Learn more about TapRooT® at You may purchase the books through the TapRooT® store. Subscribe to the TapRooT® Healthcare Newsletter here.

About System Improvements Inc. – TapRooT®

Founded in 1988, TapRooT® solves hurdles every investigator faces. TapRooT® root cause analysis takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, incident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger pointing and blame, improving equipment reliability, and fixing operating problems.

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Susan Napier Sewell
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