Oh, the Pressure! (Reducing Cases of Stage III and IV Pressure Ulcers)

By ThinkReliability Staff

Stage III and IV pressure ulcers have been added to the list of hospital-acquired conditions whose treatment will no longer be reimbursed by Medicare. Pressure ulcers are also on the list of “Never” events, or incidents that should never occur at healthcare facilities, and can lead to serious complications from patients who suffer from them. It is imperative that healthcare facilities reduce the risk of patients contracting pressure ulcers.

To reduce the risk of pressure ulcers, a root cause analysis can be performed. Not only can we use root cause analysis to determine the causes of incidents that HAVE occurred at our facility, we can outline the ways incidents COULD occur, or, in this case, what is required for a patient to contract pressure ulcers. For this, we use a proactive Cause Map (or visual root cause analysis).

We start our analysis by examining the impact to the goals. There are many impacts to the goals, but we will just focus on two: the patient safety goal is impacted by a patient contracting a stage III or IV pressure ulcer, and the compliance goal is impacted because this is a “never” event. To continue the Cause Map, we ask “What caused this?” and put the answer to the right. So when we ask “What caused the pressure ulcer?” we write “Death of tissue.” We then continue through the Cause Map this same way.

Death of tissue is caused by poor skin condition and mechanical damage to the tissue. Poor skin condition can be caused by a number of things, including poor environment, contaminants on the skin, and inadequate nutrition.

There are three types of mechanical damage to skin that causes pressure ulcers. These are shear, friction, and pressure injuries. Shear injuries can be caused by the head of a patient’s bed being elevated (so that the skin pressed against the bed is damaged as the rest of the body tends to be pulled downwards by gravity). Friction injuries can be caused by skin being drug over skin linens (to reposition an immobile patient, for example) or by bony prominences (such as knees and ankles) contacting each other. Pressure injuries are generally caused by a patient remaining in the same position. Causes of this are lack of knowledge about pressure ulcers, and being unaware of a specific patient’s risk.

There is more detail that can be added to this root cause analysis, but for the purposes of this example we will stop here and begin looking at solutions. Any cause box on the map can have a solution, or several solutions, but not every box will have a solution. Some solutions that have been compiled from various resources are shown in green boxes. Both the Cause Map and solutions can be broken out into more detail, depending on the needs of the organization.

Click on “Download PDF” above to download a PDF showing the Cause Map.

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Type AB? Negative. (ABO-Blood Incompatibility)

By ThinkReliability Staff

Blood incompatibility is a Sentinel Event as defined by The Joint Commission. If a blood incompatibility incident occurs at a medical facility, a root cause analysis is required for the event. What would the root cause analysis look like? We will look at a proactive Cause Map (visual root cause analysis) and associated Process Map as an example.

A recipient being given incompatible blood product is an impact to the patient safety goals (as well as other goals, but we’ll start simple). This could occur if the ABO blood type is identified incorrectly, probably due to mislabeling. It could also occur if the recipient’s blood type is identified incorrectly, possibly due to the recipient test specimen being mislabeled. Or it could occur if blood product is given to the wrong patient due to misidentification of the recipient. There are many other ways it could occur, but these three errors are the source of many blood incompatibility incidents.

As we enter these causes into our Cause Map, we note that these are all procedural errors. When procedural errors appear in the root cause analysis, making a Process Map can assist in the investigation. To make a Process Map, we start with the very basic process. For example, to perform a blood transfusion, we order a transfusion, take a sample from the recipient, test that sample while prepping the patient for a transfusion, pick up blood product from the blood bank (which was deposited there at some point previously), perform the blood transfusion, and then monitor the recipient for reactions.

Then we go into more step by step detail outlining portions of the transfusion process. Then we can identify the specific steps of the procedure that can lead to blood incompatibility incidents when performed incorrectly. This allows us to come up with procedural solutions (such as having a second medical professional positively identify the recipient) that focus our attention on the steps most likely to be performed incorrectly or most likely to lead to serious errors.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map.

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Another Bubble You Don’t Want to Be Part Of (Air Embolisms)

By ThinkReliability Staff

Air embolism (an air bubble trapped in the blood vessels) in hospital patients is one of the “never” events that will no longer be reimbursed by Medicare. It can also cause patient death, stroke, heart attack, or other serious complications. Thus it is in the best interest of medical care facilities to reduce the occurrence of air embolisms. In order to do this, first we must determine the causes of air embolisms. We will do this as a root cause analysis example.

Many people think of root cause analysis as a tool to determine what WENT wrong, but it can also be used to determine what COULD go wrong. We will look at the issue of air embolisms in a Cause Map to determine the causes, and then the solutions that can be implemented to reduce the occurrence of air embolisms.

For step 1, we outline the problem. The problem here is air embolisms. They affect the vascular system and often occur during surgery or as a result of using a catheter. Air embolisms impact the patient safety goal because they can cause tissue damage, serious injury, or even death. It impacts the compliance goal because it is a “never” event, and impacts the materials and labors goal because (according to Medicare data) it results in an average hospital bill of over $71,000 (which may not be reimbursed). There are approximately 57 cases/year (Medicare data), resulting in an annual cost of over $4 million.

Step 2 is the analysis. We begin with the impacted goals (we’ll look at the patient safety and compliance goals here). These goals are impacted by an air embolism. For an air embolism to occur (i.e. for air to get trapped in a blood vessel), the vasculature must be exposed to air AND the pressure gradient must favor air entering the blood vessels (normally it would be the other way around – if a blood vessel is opened, blood will come out rather than air going in). The pressure gradient could favor air entering blood vessels if surgery above the heart is performed upright or due to low central venous pressure. This could be caused by decreased blood volume or deep inspiration, such as coughing or laughing (there are case studies of post-surgical patients keeling over after a good joke).

There are several ways the vasculature can be exposed to air. Removing a catheter or performing surgery may expose blood vessels to the atmosphere. Additionally, air can enter the blood vessels through a catheter. This can occur if the catheter is damaged or opened, or if air is forced into the catheter.

Even more detail can be added to this Cause Map as the analysis continues. As with any root cause analysis investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.

Once the Cause Map has been completed to desired detail, we can look for solutions. Any cause on the Cause Map can have a solution (or more than one), but not all causes will. Here we’ve identified some of the best practices towards preventing air embolisms.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

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You left WHAT in there? (Foreign Objects Retained After Surgery)

By ThinkReliability Staff

Leaving a surgery sponge (gossypiboma) or other foreign object in a patient’s body can cause serious complications or even death. According to Medicare data, there were 750 such cases in 2007, which cost an average of $63,631 per hospital stay. That’s more than $47 million a year, and does not include potential legal costs associated with such events.

We can examine the problem of post-surgery foreign object retention by putting it into a visual root cause analysis (or Cause Map). A foreign body may be left inside a patient if it is not visible in their body, is not detected by radiography, and is not recognized as missing. We continue to ask why questions to fill out our root cause analysis.

Why would the object not be detected by radiography? The object may not be detectable by radiography, as some sponges are not. The object might not be noticed in the radiography, if the person reading it is not adequately trained, or if there is no double-check. Or, radiography might not have been used. This is contrary to some organization’s recommended procedures.

How would the object not be recognized as missing? The instrument/sponge count may be inaccurate, or it may not have been done at all, which is also contrary to recommended procedure.

Since we have “Did not follow procedure”, we need to outline what the proper procedure should be. We call this a “Process Map”. Here we show the procedure for instrument and sponge removal verification. Instruments and sponges are counted before, and twice after surgery. If the count does not match, there is a physical re-examination, and radiograph to determine whether the object has been left inside the patient. Different organizations may use a slightly different process, but what is important is that it is formalized and examined in the case of any incidents, such as a left-behind sponge or instrument.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map made with our root cause analysis template.

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