Monthly Archives: October 2010

Root Cause Analysis

Cholera Outbreak in Haiti

By ThinkReliability Staff

Although the World Health Organization (WHO) has never seen cholera in Haiti before, it’s not a great surprise that an epidemic has spread through crowded makeshift camps where people have been living since the earthquake in January.  Unsanitary conditions frequently lead to outbreaks of the disease and in situations where there is very limited access to healthcare and clean water, death rates are often high.   The death rate in Haiti was nearly 10% at the beginning of the outbreak. It’s now decreased to 7.7% which is still well above the 1% death rate threshold accepted by the United Nations (UN).

We can do a closer examination of the causes contributing to this issue in a Cause Map, or visual root cause analysis.  The first step to the analysis is to capture information about the issue and define the problem with respect to an organization’s goals.  The problem can be defined as a cholera epidemic with a high death rate.  It was first discovered, or at least reported, in November of 2010 at makeshift camps in Haiti.  We’ll use the goals of the Haitian government to determine impacts.  At least 284 people have died and 3,600 people have been infected with cholera. This is an impact to the population safety goal.   The high death rate indicates a failure of population services from the government.  The environmental goal is impacted by the epidemic spread of the disease, and  the financial goal is impacted by the cost of treatment of those afflicted.

The second step of the analysis is to determine the causes that led to the impacted goals.  The high number of deaths results from the high number of infections and the high death rate.  Infections are caused by ingestion of contaminated food and water.  The bacteria that causes cholera is spreading due to heavy rains and the large number of people living in the unsanitary conditions.  The overcrowding in the camps is due to the earthquake that hit Haiti on January 12, 2010.  As previously mentioned, it’s unclear how the  bacteria got there in the first place, but not surprising that it did.  The high death rate is due to untreated dehydration.  Severe diarrhea is a symptom of a cholera infection, and with inadequate medical care and lack of access to clean water, the dehydration can quickly become severe enough to lead to death.

Support organizations like the WHO are desperately trying to stop the spread of the epidemic and reduce the rate of death.  However, it’s clear they have their work cut out for them, given the current circumstances.

Root Cause

Using Root Cause Analysis to Achieve Organizational Goals

By Kim Smiley

The Commonwealth Fund’s healthcare improvement website (www.whynotthebest.org) provides case studies of medical facilities that have been improving various performance measures.   One of these cases involves Holland Hospital, in Michigan, which has improved its pneumonia process-of-care over the last five years and is now in the top three percent of hospitals in the U.S. for these core measures.

The process for establishing goals and implementing process improvements to meet those goals is the same process that is used for Cause Mapping.  I’d like to highlight some of the tips from Holland Hospital’s success.  (You can read the whole case study at http://www.whynotthebest.org/contents/view/61.)

Establish a team to develop and work towards goals:  The hospital’s “core measures leadership team” contains physicians, clinical directors and other leaders to ensure buy-in from those closest to the work and management.  The team meets to review noncompliant cases (called “opportunities for improvement”) on a monthly basis.  Additionally, the hospital created a respiratory disease core measure team which developed improvement strategies specific to the pneumonia core measures.

Focus on the system, not on blame: According to the hospital’s director of quality and risk: “the hospital’s patient safety culture means being blame-free. Unless the case is egregious, we assume mistakes occurred because the established care process failed our staff and/or physicians.”  Rather than focusing energy on assigning blame, the team focuses on improving systems to reduce the occurrence of similar incidents, improving the core measures performance for all staff members, not just the ones involved in the noncompliant cases.  As an example, the hospital increased screening for the pneumonia vaccine by reprogramming the electronic nursing record to require an answer to

Get everyone involved: If performance goals are met, and money is available, a bonus pool is established for all full-time employees (even those not directly involved in patient care), except hospital executives.  If the performance goals are not met, no bonus money is distributed.

Adjust responsibilities when necessary: The hospital discovered some difficulties with one measure – taking a blood culture prior to giving antibiotics.  The team discovered that there was a delay in taking the blood culture because a phlebotomist had to be called into the emergency room.  The team also discovered delays in administering antibiotics when a patient was transferred to another unit from the emergency department. A process change resolved these difficulties.  Emergency room nurses now take the blood culture (contacting a phlebotomist assigned to the emergency department if necessary) and administer the first dose of antibiotics before the patient leaves the emergency department.

Root Cause

New Research May Lead to Reduced Deaths from Sepsis

By ThinkReliability Staff

Sepsis kills about 200,000 people in the U.S. every year, about 30% of those afflicted. Millions die every year from sepsis worldwide.

Sepsis is a whole-body inflammatory state that occurs in the presence of an infection, and was previously known as a blood infection. The exact causes of sepsis are unclear. However, new research from Portugal’s Instituto Gulbenkian de Cienci has shown that during sepsis, red blood cells may be injured and leak a substance called heme. In combination with inflammation that is present during an infection, the high levels of heme become toxic to the body’s organs, causing organ failure.

The body produces a substance called hemopexin that cleans up the leaking heme. However, as levels of heme rise, levels of hemopexin fall, increasing the amount of heme in the body. The Instituto Gulbenkian de Cienci researchers have had success injecting mice with hemopexin to aid their body in reducing levels of heme. We can show the results of their research in Cause Mapping form, which can be viewed by clicking “Download PDF” above.

This potential solution to reduce the impact of sepsis still requires more research before it can be applied to humans, but may indicate a first step towards reducing the high impact of sepsis on mortality.