Monthly Archives: July 2010

Root Cause Analysis - Incident Investigation

Tackling Injuries in the NFL

By Kim Smiley

It’s no secret that a lot of players get hurt in the National Football League (NFL).

But why does this happen?  Why do so many players get hurt?  And what may be a better question, is there a way to prevent injuries?

This problem can be approached by performing a root cause analysis built as a Cause Map using root cause analysis software you probably already own – Microsoft Excel.

The first step is to determine how the organizational goals are impacted.  In this example, the safety goal will be considered.  The safety goal is impacted because there is a potential for injury.  Causes can then be added to the Cause Map by asking “why” questions.

Why do football players get hurt? Football players routinely slam into each other and the ground. It’s the nature of football. Even when the rules are followed, football is a very physically demanding sport with a potential for injuries to occur.

Another reason players get hurt is that they are wearing inadequate protection to prevent injury. Right now the rules only require uniforms, helmets and shoulder pads.  Most players wear very little padding because they want to maximize their speed and mobility.

As a potential solution to this problem, NFL officials are reconsidering the rules that govern the pads worn by players. Currently knee, hip and thigh pads are only recommended, but there is possibility that this will be changed for the 2011 season.

Twelve teams will experiment with lightweight pads during training camps and preseason games this year.  The players will have the option to continue wearing the pads during the actual season if they want.

Depending on the outcome of the trials, there is the possibility that additional padding will be mandatory starting in the 2011 season.  Hopefully, the additional padding will be successful at preventing some injuries, but only time will tell.

Root Cause Analysis - Incident Investigation

Impure Injections Used

By Kim Smiley

Research is been suspended at a prominent brain-imaging center associated with Columbia University.  Food and Drug Administration investigations found that the Kreitchman PET (positron emission tomography) Center has injected mental patients with drugs that contained potentially harmful impurities repeatedly over the past four years.

Investigations by the lab determined that no patients were harmed from the impurities, but this is still a significant issue in a nationally renown laboratory.

How did this happen?

This issue can be investigated by building a root cause analysis as a Cause Map.  To start a Cause Map, the impact to the organization goals is determined.  In this example, this issue is obviously an impact to safety because there was potential to harm patients.  It is also an impact to the production-schedule goal because research has been suspended.  Additionally, this problem is an impact to the customer service goal because this issue raises questions about the validity of research results.

To build a Cause Map, select one goal and start asking “why” questions to add causes.  In this case, the first goal considered will be the safety goal.  There was a potential for injury.  Why?  Because impure injections were given to patients.  Why?  Because the injections are necessary for research, because the labs typically prepare the compounds themselves and because the lab prepared the compounds incorrectly.  When there is more than one causes that contributed, the causes are added vertically with an “and” between them.

Each impacted goal needs to eventually connect to the same Cause Map.  If they do not, the impacted goal may not be caused by the same problem and the goals should be revisited.

To continue building the Cause Map, keep asking “why” questions for each added cause until the level of detail is sufficient.

A Cause Map can be as high level or as detailed as needed.  The more significant the impact to the goals, the more likely a detailed Cause Map will be warranted.  Once the Cause Map is completed, it can be used to develop solutions to help prevent the problem from reoccurring.

In this example, the lab is currently changing management and reorganizing procedures to help prevent the similar problems in the future.

To view an initial Cause Map for this issue, please click the “Download PDF” button above.