Monthly Archives: September 2009

Root Cause

Which ankle needs surgery? Neither? Oops . . . (Wrong Procedure)

By ThinkReliability Staff

A patient receiving the wrong procedure is a very serious event. It has been named a “never event” by The Joint Commission. For organizations that are trying to prevent these kinds of serious events from happening, there is value in looking at near misses, such as the case we’ll examine here in a root cause analysis. 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.

In our case, a patient was prepped for a surgery he didn’t need, even receiving spinal anesthesia. He was prepped for a procedure based on the advice of an orthopedist, who believed the patient to have an ankle trimalleolar fracture, which he did not.

Why did the orthopedist believe the patient to have a fracture? The radiologist who had reviewed the patient’s radiographs diagnosed the fracture. The orthopedist did not review the radiographs. The orthopedist did examine the patient’s ankle, but gained no new insight into the diagnosis. Additionally, the family/patient did not mention the previous diagnosis, possibly because they weren’t told of it, or didn’t understand it..

The radiologist diagnosed the fracture because there was a fracture shown on the radiographs, which were labeled with the patient’s name. However, it was later determined that the radiographs were actually of a previous imaging client. The radiographs were taken because the patient’s previous radiographs did not arrive in time.

Given no more information about this case, our analysis stops here. However, the next step for the medical facility involved would be to examine the radiography procedures to ensure that mislabeling incidents do not occur. Other causes listed in the map can also be examined, to determine where other improvements can be made.

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..

Root Cause

Patient Killed By Operating Room Fire

By ThinkReliability Staff

In a previous blog, we looked at possible causes of patient burns, including operating room fires.  Sadly, on September 8th, a patient passed away, six days after being burned during surgery.  (See the news article.)  Due to patient safety laws and ongoing investigations, there is no information suggesting what could have been the causes of the fire.  However, as with any fire, an operating room flash fire, like the one suspected in this case, requires 3 things:

1)  a heat source – typically in the operating room the heat source is provided by electrical surgical equipment.

2) oxygen – patients under anesthesia may be receiving 100% oxygen, providing an extremely oxygen-rich environment for fires.

3) fuel – the disposable synthetic fabrics primarily used now are more flammable than cloth drapes.

Since all three of these causes are required for a fire, removing any one of the causes will prevent a fire.  However, in an operating room environment it’s not practical to remove any one of these causes, so instead we can work on reducing the risk by mitigating the effect of each of these causes.  To reduce the risk from the heat source, surgeons are warned to leave electrical tools in standby mode, or turned off, whenever they are not in use.  To reduce the concentration of oxygen in the air, anesthetists may be asked to provide only as much oxygen as needed for the patient, and avoid creating places that oxygen may concentrate, such as under the drapes.  More flame-resistant material is being considered for use in some operating rooms.  Additionally, more and more operating room teams are providing training in preventing and extinguishing surgical fires, because although only an extremely small percentage of surgeries result in fire, the results can be catastrophic.

Root Cause Analysis

Childhood Obesity – A Community Problem

By Kim Smiley

It takes a village to raise a child . . .and to keep one from becoming obese. Childhood obesity is now being recognized as, at least partially, a community problem with community-based solutions. At the peak of the “obesity epidemic”, 32% of children in the U.S. were classified as overweight and 16% were classified as obese.

Obesity can result in a greater risk of disease (more than 90% of overweight children have at least one avoidable factor for heart disease.) This is an impact to the health goal of a community, and the nation. Obesity is the result of sustained weight gain. Weight gain is a simple balance problem. If calories consumed are greater than calories expended, as a result of too many calories consumed, too few expended, or both, weight gain will result. Usually obesity is caused by both.

First we’ll look at the causes of consuming too many calories. Too many calories are consumed when children eat high-calorie, low-satisfaction foods. In many cases, this is because a child has access to these types of foods and because healthy choices are not available. This is true with family, and at school, which generally contribute equally to caloric intake. A high proportion of foods consumed at school may be unhealthy; schools must offer healthier choices. Some schools have done away with soda and candy, but more healthy choices must also be offered. Students bringing their own lunches may suffer doubly from healthy food not being available at home, due to a lack of access or affordability. The all-too-many areas in the country that do not have access to healthy food at supermarkets or farmer’s markets are known as “nutritional deserts”, most frequently found in low-income and/or rural areas. Communities must improve access to healthy food, at school and at home.

The other part of the equation is calories consumed, otherwise known as exercise. However, children don’t need time on the treadmill; they need safe places to play outdoors or a safe route to walk or bike to school in order to get exercise. They also need physical education (PE) at school, and they need to see the importance of physical activity (something their parents may not be modeling at home, based on adult obesity rates, which are extremely high as well). Low-income and/or rural areas are less likely to have safe places to play outdoors, or a safe way for children to bike/walk to school, so these children are disproportionately affected by obesity. Communities must provide an outlet for physical activity for children.

On the downloadable PDF (download by clicking “Download PDF” above), we show the causes and solutions in a Cause Map, a simple intuitive format that fits on one page. The causes are solutions shown here are from the perspective of the community – causes and solutions that can be controlled by a community. If communities began implementing these solutions, the childhood obesity epidemic would be a thing of the past.

Want to learn more? See the Institute of Medicine report, issued in 2007.

Root Cause

Sorry alone doesn’t work unless we learn from our mistakes.

By ThinkReliability Staff

The title is a quote from Timothy McDonald, a pediatric anesthesiologist and the chief safety officer of the University of Illinois Medical Center, discussing medical errors, which are now estimated to kill as many as 98,000 Americans a year.

“We have to also make promises that this won’t happen again and get patients and families engaged in the effort to improve our performance.”

The University of Illinois Medical Center, along with other medical facilities, has made great efforts to communicated with grieving family members after medical mistakes, and getting those family members involved with helping prevent future mistakes.

One of the changes implemented requires an x-ray of patients at risk for foreign objects retained after surgery. So far, the x-rays have found 8 foreign objects found left in patients , despite a manual count that claimed all the sponges were accounted for.

Some experts worry that the “increased candor” with families may increase the number of lawsuits. Dr. McDonald says that, though the number of procedures at the University of Illinois Medical Center have increased 23% since the program was implemented, the number of lawsuits has decreased 40%.

To many family members of victims of medical errors, it’s not about the money; it’s about making sure nobody else will suffer from the same mistake. Allowing these family members (or the victims themselves) to help improve the processes that led to the errors may ease their concerns. (View the news article in the Wall Street Journal.)

Root Cause Analysis

Emergency Generators: A Loss of Power Doesn’t Mean a Loss of Life

By ThinkReliability Staff

If you are working at a healthcare facility, you most likely have an emergency generator. However, that emergency generator probably powers only certain critical sections of the facility, and it probably doesn’t include the administration part of the building. Why is that so?

We can look at impacts to the goals to determine why a solution that’s successfully implemented to solve a problem at one location or organization may not be the right solution for another organization. In a hospital, a loss of power could impact the goals pretty severely – the risk of death to the patients impacts the safety goal, the loss of life-saving equipment impacts the customer service goal. Additionally, the production goal may be impacted because the facility is unable to enter new patients. Last but not least, an additional cost (impact to the materials/labor goal) may be incurred transferring patients to a new facility. Obviously the risk of death means a HUGE impact to the organization’s goals, demanding comprehensive reliability solutions.

Compare this to an office building, such as where our administrative offices would be. If a loss of power occurred, the goals would be impacted – employees could get injured leaving the building if the lights went out. This is an impact to the safety goal. We may lose our business function during the outage, which would be an impact to the customer service and production goals. Additionally, we may have to pay our employees for a non-work day. The goals are impacted, but the severity of the impacts pales compared to the impacts of a hospital or medical facility losing power.

If we create a Cause Map based on these impacts to the goals, it shows that all the impacts to the goals tie back to a loss of electrical power, caused by both a power outage AND a lack of back-up electricity source. (The Outline and Cause Map are shown on the downloadable PDF.)

When determining solutions, there are a few that come to mind, including transferring patients to another healthcare facility (which becomes an impact to the goals) and installing battery backups in equipment. However, because of the severe impacts to the goals, a hospital will likely decide that the whole problem can be solved by installing an emergency generator. Problem solved; we have been able to find the best solution.

The administrative offices may feel differently. The cost of installing an emergency generator is large, and if we compare that cost to the costs that would be incurred due to a loss of power without backup, it’s probably not worth it. Instead, the office building may implement solutions further to the left on the Cause Map, such as installing emergency lighting, or using battery backups, that would mitigate (but not prevent) the impacts to the goals. So, just because a solution was the “right” solution in one case, it may not be in every case.

View the Outlines and Cause Maps for both the hospital and office building by clicking “Download PDF” above.

View the Joint Commission’s article on Power System Failures.