A Perfect Corrective Action

by Jim Franklin

Not long ago, my 15-year-old daughter, who has type one diabetes, became severely ill and needed to go to the emergency room.

Type one diabetes—which accounts for 5 to 10% of all diabetes cases1—is a condition in which the pancreas stops producing insulin, a chemical the body requires to use sugar as food. People with type one diabetes must keep a careful watch on their diets and regularly inject themselves with insulin to remain healthy.

They also must monitor their blood-glucose levels—if there is too little insulin or too much sugar in the body, the unprocessed sugar stays in the bloodstream and shows up as a high blood glucose reading. Sick days can be difficult for a person with diabetes.

Upon my daughter’ admission to the hospital, we learned her nausea was in fact caused by elevated sugar levels and she was in the early stages of diabetic keto-acidosis. This condition results when the body is unable to process sugar due to lack of insulin and attacks its own fat cells in an attempt to feed itself.

The waste materials (ketones) from this process build up in the bloodstream and the blood becomes increasingly acidic. If untreated, it can become fatal in a matter of days.

We were aware her sugar levels had been difficult to maintain over the last couple months but were at a loss as to why. The only trend we had noticed through plotting her blood glucose readings was that they often would be fine in the morning but elevate over the course of the day. Any corrections our daughter was making to the insulin doses to remedy this seemed to have no effect.

Once she had stabilized in the hospital, we asked the specialists for possible causes. They offered two possible explanations: not enough insulin or too much sugar. She either must be skipping insulin injections or cheating on her dietary restrictions. We knew neither was the case.

After returning home with few answers, we were dismayed when within 10 hours her blood sugar had gone from being in the acceptable range to more than 2.5 times that with no explanation. We contacted one of the specialists at 3:00 a.m., and he recommended a change in the insulin dosage but still had no new ideas—outside of our daughter’s cheating—as to how this had happened.

I guess I have been a quality assurance manager for too long. I know my daughter well enough to know she takes great pride in managing her diabetes on her own and would neither skip injections nor cheat on her diet. I looked at the chart we had main-tained to try to make some sense of what was happening. To help determine the cause, I used a standard fishbone analysis. This tool organizes what may be a long list of causes into four major areas—man, materials, machine and method.

The four areas in this case were:

  1. Man (person): Was there an underlying condition that caused the illness? Was she cheating on dosages or diet?
  2. Materials: Were the insulin and blood testing strips OK?
  3. Machine: Was any of the testing or injection equipment malfunctioning?
  4. Method: Was she using the equipment correctly?

Figure 1 shows the resulting fishbone diagram. Our investigation and records showed none of the causes associated with the man, materials and machine categories were present. As for methods, my daughter uses two to inject insulin. The first is by using a syringe—withdrawing the required amount of insulin from a vial and injecting it under the skin. My wife and I had seen her do this numerous times and knew it was not the problem.

Figure 1: Fishbone Diagram

The second method is by using an injector pen. She generally uses syringes in the morning and the injector pen for the balance of the day. With this method, the insulin is contained in a cartridge in the pen. She turns a dial to set the dosage, causing the end of the pen, or plunger, to move outward. Depressing the plunger injects the insulin through the needle into the skin and spins the dial back to the zero position.

I asked my daughter to show me how she was using the injector pen. Her method seemed OK to me. However, I looked up the manufacturer’s manual on the internet, and it showed a different method. I got the pen and, using the manufacturer’s instructions, squirted insulin out of the needle. I then used it the way that she had been, and nothing came out.

In looking at the chart we had put together, this cause explained everything. I spoke to my daughter about it later that morning. When she used the pen, she dialed in the correct dosage, but instead of depressing the plunger to deliver the insulin, she was just turning the dial back to zero.

This caused the plunger to depress, making it appear as though insulin had been injected when it really had not. She had changed her method because it was difficult to use the pen properly when injecting larger doses. Since she began using the pen properly again, she has been able to easily manage her blood glucose levels.

When determining the root cause of a problem, whether inside or outside our work environment, it is important to investigate all areas in which failure can occur. Using a fishbone analysis ensures this. In my daughter’s case, this method revealed the single root cause. It turned out to be the perfect corrective action in that it explained both the lack of control as well as the daily trend of her sugar rising from morning to evening.

It is rare to have a corrective action that answers everything and even more gratifying when it concerns the health of someone you love.


  1. American Diabetes Assn., www.diabetes.org/about-diabetes.jsp.

JIM FRANKLIN is a quality management system training manager for Samuel Son & Co. in Hamilton, Ontario. He has an engineering technology diploma in metallurgy from Mohawk College in Hamilton. Franklin is a member of ASQ and a certified quality manager.

Great story. I was looking for examples of good RC methods for the manufacturing department. Hope she is still doing well.

--Charlie Poirier, 02-26-2016

Excelente art??culo, he recomendado a muchas personas su lectura para ver la importancia de vivir con un pensamiento enfocado en calidad.
--Jose Rivas, 04-01-2008

I agree with all other comments - just excellent job!
--Beata Luczak, 03-25-2008

Great job, thanks for sharing and best wishes to your daughter
--Minh Nguyen, 03-18-2008

applause to Mr.Franklin for using a great tool to investigate and come to a conclusion that aids the health of his daughter, now if we could get Doctors to implement some of these approaches maybe a second opinions would not be required.
--Patricia Mazurek, 03-14-2008

Very fine example of a corrective action and RCA.
--Hari Taneja, 03-14-2008

Great article,Thanks for sharing,best wishes to you and your danghter!
--Jianqing Chai, 03-13-2008

--Anne Cooke, 03-13-2008

I would never think to apply corrective action analysis in my personal life but this was really great, and I wish your daughter a helthy life.
--Muath F. Madi, 03-13-2008

Thank you for this deep insight into root cause analysis through fishbone. It is one of the best explanations in that matter I have read!
Best wishes to your daughter!
--Karl Heinz Scherling, 03-13-2008

Excellent article! Clearly stated. Wonderful example. Thank you. The next step is to work with the manufacturer to resolve the user interface problem of the injector pen giving the appearance of an injection when none is given. It is likely your daughter is not the only person tricked by this misperception.
--Becky Cummings, 03-12-2008

Kudos for applying a great problem solving tool in a critical situation and sharing it with us. Hope you won't mind if I use it in my training efforts.
--Ajit Shirodkar, 03-12-2008

--Debbie Anderson, 03-12-2008

Thank you and your daughter for allowing all of us to see into a very personal matter. This example should be a lesson to all about focusing on the situation with the goal to resolve the problem.
--Chris Santarcangelo, 03-12-2008

Great article, brief and to the point, to illustrate how useful the fishbone diagram can be, from a fairly straightforward example.
--Rob Lebby, 03-12-2008

Great use of the many quality tools at our disposal.
--Robert McCray, 03-12-2008

This was a remarkable experience on how we can use quality tools to solve everydays' problems and find corrective actions that remedy situations we encounter. You are the icon of quality.
--calvin Otundo, 03-12-2008

--Deepak Dev Arora, 03-12-2008

I am Dir of Continuous Improvement for a consumer products company. I also have a daughter with type 1 diabetes and could relate to the problems you described. More importantly I have a very hard time teaching root cause analysis and effective corrective action. I will use this story as a great example.

Thank You!
--Judy Scott, 03-12-2008

This article was one of the best examples of root cause analysis that I have seen.
Great example for using tools in personal life that are normally thought of as only work related.
--Caren Bozich, 03-12-2008

This article is both heartwarming and practical at the eame time. My heart goes out to your daughter and the disciplined lifestyle she is required to live. I also realize that this is inappropriate because any response leading t o self-pity is counter productive to leading as normal a life as possible within the parameters of Type I diabetes. Kudos to your daughter, she is one of the unsung heroes of her generation and certainly appears to be a role model for others in her situation.

Although we did not have anything that serious with my youngest son, he did have a problem that his pituitary gland was not producing any or insufficient growth hormone to stimulate normal growth. He had to take daily injections of growth hormones for about 5 years using what is probably the same type of epi-pen and I can see how your daughter had the problem with it she did.

Next, this is the very first (and best) time that the fishbone diagram made any sense. Your description of its usage from development to reaching the corrective action was nothing but elegant and easy to understand. I've been in seminars where this was taught, but I never got it til now.

THANKS and best wishes to your daughter,
Andrew M. Brody
Quality Systems Manager
Marcus Paint Co.
Louisville, KY 40202
--Andrew M. Brody, 03-12-2008

This was an awesome story. To apply the knowledge of corrective action to a personel situation like this was brilliant, not to mention the time to do all this and not depend on others. Mr. Franklin should be commended for his efforts.
--Tami Payne, 03-12-2008

This article is wonderful, thank you for sharing.
--Sarah Cleasby, 03-12-2008

The systematic approach to assessing the root cause was instructional. A number of us need those periodic reminders that quality management is both science and art.
--Randy Blanton, 03-12-2008

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