Monthly Archives: August 2009

Never Event, Root Cause Analysis

We Regret to Inform You We’ve Removed the Wrong Leg . . .

By ThinkReliability Staff

Performing surgery on the wrong body part or wrong-site surgery is a “never event” as defined by the National Qualify Forum (NQF), and can have serious health consequences for a patient.

We can use a Cause Map to determine some ways to prevent wrong-site surgery. Some of the common errors leading to wrong site surgeries are presented in the Cause Map found on the downloadable PDF. They include: time pressure, lack of paperwork, misreading radiography, not marking or incorrectly marking the surgical site, and marking the wrong site.

Once the root cause analysis is complete, solutions are brainstormed and placed with the cause they control. In this example, we use the solutions to create a basic Process Map for the surgical preparation procedure to prevent wrong site surgeries. The solutions are numbered based on the order they appear on the Process Map. It’s clear that consistent adherence to this Process Map would result in fewer wrong-site surgeries.

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

Go to Root Cause Analysis Healthcare Home Page

Hospital Acquired Condition, Root Cause Analysis

UTIs: Painful for the Patient AND the Hospital, too!

By ThinkReliability Staff

According to Medicare data, there were 12,185 cases of Catheter-Associated Urinary Tract Infections (UTIs) in the year 2007, which resulted in an average $44,043 hospital stay. These cases represent more than $500 million in this preventable, hospital-acquired condition. As a result, Medicare and Medicaid will no longer cover costs associated with UTIs if they were not present at admission to a medical facility.

In order to work at preventing these conditions, first we must examine how they occur. We’ll do this by looking at Catheter-Associated Urinary Tract Infections in a visual root cause analysis (or Cause Map).

A UTI is an impact to our patient safety goal. A UTI is caused by pathogens accessing the urinary tract and not being removed. We will look at each of these causes in more detail. Pathogens access the urinary tract when a urinary catheter is inserted. The catheter may be used for obtaining urine, because a patient is incontinent, or to permit urinary drainage.

In order for pathogens to access the urinary tract on a catheter, there must be pathogens on or in the catheter. These can be pathogens already in the body, contamination from the drainage system, or pathogens transferred on the hands of medical personnel, or by a non-sterile insertion.

The pathogens are not removed from the body either because of an insufficient immune response caused by damage to the urinary tract by improper insertion or improper securing of the catheter. Or, the pathogens are not excreted due to an obstructed urinary flow.

Once we have determined the basic causes of a UTI from our simple root cause analysis, we can consider solutions associated with the causes. For example, if a cause is “Pathogens on hands of medical personnel”, a solution may be to require “Handwashing before and after manipulation of catheter site or apparatus.”

Click on “Download PDF” below to see the Cause Map and possible solutions. If facilities began implementing some or all of these solutions, the incidence of Catheter-Associated UTIs would decrease, and patient health and satisfaction would increase.

Root Cause

Implement Solutions Within Your Sphere of Influence

By ThinkReliability Staff

The Houston Chronicle reports disturbing news on the state of healthcare safety and reform.    They reported that:

“Experts estimate that a staggering 98,000 people die from preventable medical errors each year”

“A federal Centers for Disease Control and Prevention study concluded that 99,000 patients a year succumb to hospital-acquired infections. Almost all of those deaths, experts say, also are preventable.”

Not only do almost 200,000 people a year die from preventable errors or infections acquired in hospitals, but, according to expert federal analysts, the rate of these deaths may actually be increasing.  Part of the problem is that the recommendations provided by experts, federal and private studies and various other resources are not being implemented quickly – or at all.

Some people think that the root cause analysis investigation process ends when solutions are recommended.  In fact, the hardest part may be just beginning.  There’s a reason we refer to solutions as “action items” – they require action.  They also require follow-up.

Proper follow-up will determine if solutions are being effectively implemented, i.e. the problem is being solved.  In this case, that would be the number of medical errors are decreasing.  Since that’s not happening, the next step is to determine why the action items were ineffective.  Right now, the recommended action items aren’t effective because they aren’t being implemented.

An organization can only effectively implement solutions that are within its sphere of influence.  Medicare, for example, is attempting to influence medical errors by using its most effective weapon – its pocketbook.  Medicare is no longer reimbursing for certain medical errors, and hopes to add to the list.  As many private insurers follow suit, more healthcare facilities will find it necessary to change the way they do business . . . and then hopefully the medical error rate will begin to decrease.

Learn more about finding solutions.

Root Cause Analysis

Fighting Back Against Drug-Resistant Malaria

By ThinkReliability Staff

A study published in the New England Journal of Medicine shows that malaria is becoming resistant to the most effective anti-malarial drugs currently available, known as artemisinin-based combination therapy. This therapy involves two drugs – artemisinin, which acts and leaves the body quickly for a “shock” to the parasites that cause malaria, and mefloquine, or another related drug, which stays in the body longer and cleans up the rest.

Since there are currently no equally effective replacement drugs or a vaccine for malaria, an increase in the drug-resistance of malaria may increase the number of deaths from malaria. In 2006, malaria was responsible for nearly 1 million deaths, according to the World Health Organization (WHO).

A Cause Map built using a root cause analysis template can visually explain the causes leading to drug-resistant malaria in a simple, intuitive format that fits on one page. (To view the Cause Map, click on “Download PDF” above.)

A risk in the increase in deaths from malaria is caused by people being infected by malaria, and ineffective malaria treatment. Nearly 250 million people a year are infected with malaria, due to exposure to mosquitoes in an endemic area, no vaccine and no preventive drugs (which are expensive and can have side effects with long-term use). Ineffective malaria treatment can be due to counterfeit drugs, which are estimated by WHO to comprise up to 40% of the drug supply. Counterfeit drug distribution is increasing due to a lack of security of the drug supply.

Additionally, the increase in drug-resistant malaria means that existing treatments are less effective. (Counterfeit medicines are a double whammy in that they also contribute to drug resistance.) Drug resistance generally occurs when an infected person takes a not-quite-whole course of treatment. The treatment kills off most of the bugs, leaving only those strong enough to resist. When these “super” bugs then reproduce, the resulting generations are more likely to be drug resistant. (This is what’s been happening in the U.S. with some antibiotics.)

The most effective (and WHO recommended) course for malaria is the combination therapy discussed above. Unfortunately, the mefloquine class of drugs have severe adverse side effects, including nausea, vomiting, and nightmares. When the two medications are given separately, some people chose not to take all (or any) of the mefloquine to avoid these side effects. A possible solution is to only offer the two together, in a combination pill.

The WHO and other organizations continue to work on this problem. An experiment in Europe recently used weakened mosquitoes as “flying vaccines” for malaria, with some success. Until then, the use inexpensive preventive measures such as mosquito nets and indoor spraying continues to increase.

To learn more about diseases carried by mosquitoes, see our yellow fever blog posting.