Monthly Archives: November 2009

Root Cause Analysis

How to Determine Your Organization’s Goals

By ThinkReliability Staff

The first step of the Cause Mapping strategy of root cause analysis is to define the problem with respect to the organization’s goals.  In order to do this, you need to know what an organization’s goals are.  While we provide Cause Mapping root cause analysis templates that will give you an idea of where to start, your organization may wish to personalize their investigations so that they correspond to your particular goals.

To define your organization’s goals, try to imagine a perfect day for your organization.  For the healthcare industry, that perfect day doesn’t include anyone getting hurt or killed due to the actions (or lack of action) of the organization’s employees.  This is the patient safety goal.  Additionally, a perfect day would not include any injuries or deaths of employees.  This is the employee safety goal.

Additionally, most industries have a goal of not impacting the environment.  However, a healthcare industry may have a base level of environmental impact, such as a standard amount of hazardous waste disposal or an appropriate number of x-rays.  In this case, your goal might be to not surpass that level rather than having no impact.  This is the environmental goal.  Environmental impacts usually result from leaks or spills of any material other than water, but may also result from improper storage or disposal of hazardous material.  Misuse of diagnostic equipment such as radiographs may result in an environmental impact.

The medical and insurance industries have defined some events that should not happen on a perfect day.  The Joint Commission has its list of “never events” which are events that should never happen, and Medicare has a list of “hospital acquired conditions” which are conditions caused or worsened by medical provider actions for which Medicare will no longer reimburse.  This is the regulatory or compliance goal.

A healthcare organization exists to provide services to its patients.  If patients are not receiving appropriate services in a reasonable amount of time, this impacts the patient services goal.

Another area of concern for almost all organizations is cost.  An incident that results in additional costs to the organization impacts the material and labor goal.  If an incident results in many costs, it’s possible to itemize them within the problem outline.  Quantifying all the costs associated with an incident can help prioritize which incidents require the most immediate attention.  It also provides a bound for the cost of solutions – installing a $100,000 machine to solve an infrequent $20,000 problem doesn’t make sense.  (Of course, for incidents that involve impacts that can’t be easily quantified – human safety, regulatory requirements, patient services, etc.  – these impacts must be considered above and beyond the “cost” of the incident.)

Once you’ve determined all of the goals that are meaningful to your organization, you’re ready to make an outline for the first step of the Cause Mapping method of root cause analysis – define the problem.  But what order do you put the goals in?  Generally, the goals go in order from most to least important.  The safety goal is almost always at the top.  Your organization’s mission statement is an excellent resource to determine the order of the goals.  Ideally, they’ll follow along with your mission statement, with any goals not specifically called out (such as the “material and labor” goal) listed below.  It’s also possible to use a different order so that the biggest impacts from an incident are listed at the top.  However, your organization may prefer to always use the same order for consistency.

If an incident resulted in no impact to one of your organization’s goals, don’t delete the goal from the problem outline.  Instead, write “N/A” next to the goal.  That way, it’s clear that the goal was considered but it was determined that there was no impact.  Deleting the goal may lead others to believe that it’s no longer a goal of the organization!  Shown below is a standard outline for a healthcare organization.

ThinkReliability has specialists who can solve all types of problems. We investigate errors, defects, failures, losses, outages and incidents in a wide variety of industries.  Visit our website to find out more about our investigation services and root cause analysis training.

Never Event, Root Cause Analysis

Fifth Wrong-Site Surgery in Two Years Results in Fine for Hospital

By ThinkReliability Staff

Last month a patient at Rhode Island Hospital received surgery on his fingers. The surgery was supposed to be on two separate fingers (one on the right hand, one on the left), but due to a medical error, both surgeries were performed on the same finger. The family was then notified and the surgery was re-performed on the correct finger.

Although there was no risk of patient death due to this medical error, it is the fifth wrong site surgery to happen at this teaching hospital in two years. Rhode Island Hospital was previously fined $50,000 for three prior wrong-site surgeries. The Rhode Island Health Department fined the hospital $150,000 for the latest incident and is requiring the hospital to install cameras in its operating room.

Although some of the details of the surgical error are unknown, it is known that rather than marking the individual fingers that were supposed to be operated on, the patient’s wrists were marked. Additionally, it was not the operating surgeon who did the markings. The operating team also did not hold a “timeout”, which is used to make sure the operating team has the right patient, right location and right surgery, before performing the second surgery. (In particularly disturbing news, after the error was noticed and the family consented to performing the operation on the correct finger, there was again no “timeout”.)

The downloadable PDF shows the outline of the problem and a very basic Cause Map. (Click on “Download PDF” above.) As more details emerge during the investigation, they can be added to the Cause Map. Once the Cause Map is completed to a level of detail commensurate with the impact to the organization’s goals, solutions can be found to mitigate the future risk.

Want to learn more?

See how else wrong-site surgeries could occur in our proactive Cause Map.

Read the news article.

Root Cause

Woman Gives Birth to Stranger’s Baby!

By Kim Smiley

Unfortunately, this isn’t a tabloid story.  On September 24, 2009, a woman named Carolyn Savage gave birth to a healthy baby boy.  However, the baby boy was not biologically hers.  The fertility clinic that the Savages had used had implanted a stranger’s embryo.  The Savages decided to carry the baby to term and then give him up to his biological parents.  (See the news story.)

However, in other circumstances where a woman has discovered she is carrying a stranger’s baby, the baby has been aborted.  Although very few women have been implanted with stranger’s embryos, the consequences of such a mistake are drastic.  Because of these consequences, fertility clinics must ensure that their procedures involve checks, double checks, and are followed by every employee in a clinic.

All people make mistakes, which is why oversight is so necessary for procedures that can lead to disastrous consequences.  In the medical field, this is why effective procedures that are followed to the letter are so important.  There have been no details released in what exactly went wrong to lead to a woman being implanted with another family’s embryo.  However, it’s certain that the fertility clinic will be forced to review its procedures, to make sure that this never happens again.