By ThinkReliability Staff

Patient death or disability associated with electric shock is one of the never events as defined by The Joint Commission. In order to reduce the occurrences of these unfortunate events, we can perform a root cause analysis on an event that has already occurred. This will allow us to apply the lessons learned to keep this type of event from happening at other facilities. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

The first step to a root cause analysis is to define the problem. On an unknown date, a patient was electrocuted and killed while undergoing heart monitoring at a medical facility. The heart monitor was plugged in to an IV pump inadvertently. We put the incident in the context of the organization’s goals: the patient safety goal was impacted because of the death of a patient; the staff was devastated, resulting in employee impact, and the compliance goal was impacted because this was a never event.

Once the problem has been defined, we use the impacts to the goals to begin the second step, analysis. Thegoals become the first cause boxes in our Cause Map. We ask “why” questions to fill in the remainder of the map. Here, the patient was electrocuted because she was hooked up to a heart monitor, and electricity flowed through the heart monitor. The electricity was present because the heart monitor lines were plugged into an IV pump, and the IV pump was plugged into the wall. The heart monitor lines were plugged into an IV pump because a staff member was attempting to reconnect the heart monitor and confused the monitor and the IV pump, and the heart monitor lines were able to be plugged in to the IV pump.

The last step is to define solutions. Here, we’ve only put two solutions, though more are possible. One is to change the adapters so that it isn’t possible to plug the heart monitor into another piece of equipment. Another is to institute a lock-out procedure, so that other pieces of equipment in the room are de-energized (if possible) or tagged to prevent confusion.

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

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

Return to Root Cause Analysis Healthcare Home Page

By ThinkReliability Staff

Patient death or disability resulting from a burn received while at a medical facility is a “never” event as defined by the National Quality Forum. Medicare has announced that it will not reimburse medical facilities for treatment required as the result of a burn obtained at that facility. Although there are many different ways a patient burn could occur, we will look at  root causes for some of the more common situations that result in a patient burn.

Serious patient burns can result from exposure to hot equipment (typically an electrosurgical device placed on the patient) or from a surgical fire. A surgical fire, like all fires, requires three things to occur: an oxidizer, fuel, and an ignition source (or heat). In surgery, the oxidizer can be provided by atmospheric air, nitrous oxide, or an oxygen-enriched atmosphere. This leg of the fire triangle is typically controlled by an anesthesiologist.

There are many fuel sources in an operating room. Common operating room material, like drapes, gowns, sterile pads and gauze, is flammable under the right conditions, as are certain volatile prepping solutions and ointments, the patient’s hair, and body gases. Fuel sources are generally under the control of the nursing staff.

The most common ignition (heat) sources in the operating room are lasers and electrosurgical devices. These are generally controlled by the surgeon.

Because the three legs of the triangle are controlled by three different people in the operating room, good communication is essential. There are also some other operating procedures that reduce the risk of a fire. These solutions are shown in green boxes on the downloadable PDF.

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

Return to Root Cause Analysis Healthcare Home page

By ThinkReliability Staff

Patient death resulting from a fall is one of the National Quality Forum’s “Never events” and death or serious disability resulting from a fall is also on the list of hospital-acquired conditions that Medicare/Medicaid will no longer reimburse for. For these reasons, as well as reasons of patient safety, healthcare facilities must work on reducing the risk of patients falling.

Because there are myriad ways a patient can have a fall, we will show an example of a specific case. In this case, a disoriented patient (who was considered a high fall risk) was left alone in an imaging room, without being strapped on, after radiographs were taken. The patient ruptured an eyeball, resulting in blindness in one eye. The medical facility involved received a fine of $25,000.

During the root cause analysis, the facility determined that the policies regarding high fall risks were not followed in this case. As a result, the facility has instituted safety education for the imaging staff, a monitoring process to ensure policies are being followed, and a program whereby a clinical staff member accompanies high fall risk patients to the imaging room. These are the solutions to the root cause analysis.

Although the analysis we performed is specific to this case, the solutions and thought process are not. To reduce falls, every facility should re-evaluate its fall risk program. Are the criteria still valid and being uniformly applied by all staff? Is there more that can be done to reduce the risk of falls? We can help you take a similar incident from your facility to help you improve safety processes.

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

Return to Root Cause Analysis Healthcare Home Page