By Kim Smiley
A new study found that nearly a third of diabetic hospital patients experienced a medication error in a one week period. The study examined bedside data for 12,800 patients and 6,600 patient questionnaires for hospitals in England and Wales. Medication errors when treating diabetics can have severe consequences because many diabetics require medication to maintain healthy blood sugar levels. Blood sugar levels that are either too high or too low can result in significant illness and even death if untreated.
The two most common errors found by the study were failing to properly adjust medication when a patient’s blood sugar level was high (23.9%) and failing to sign off on the patient’s bedside information chart when insulin was given (11.1%).
This issue can be examined by building a Cause Map, an intuitive, visual root cause analysis format. The first step to building a Cause Map is to determine the impact to the overall organizational goals. In this example, the risk to diabetic patients is an impact to the safety goal. The next step is to ask “why” questions and add the cause boxes to the Cause Map to illustrate the cause and effect relationships between all the factors that contributed to the issue.
In this example, the risk to the diabetic patients occurred because medication errors occurred and the patients required medication to maintain healthy blood sugar levels. The study did not provide details on why the medication errors were made by hospital staff, but that information could be added to the Cause Map if it becomes known. A Cause Map can be still be useful when only a high level map can be built because it can help identify an at risk population and a common problem, the diabetic patients and the medication errors, which could help identify where more research is needed or where resources could be directed. To view a high level Cause Map of this issue, click on “Download PDF” above.
A potential solution that has been suggested for this problem is to improve training for hospital staff on how to properly treat diabetic patients. A more detailed look at understanding exactly why the staff is making errors could help direct the training plan to the most needed areas.
By Kim Smiley
A new study has found that the number of children going to the emergency room because of batteries that have been swallowed or placed in the mouth, ears or nose has nearly doubled during the past 20 years. The study determined that a child visits an emergency room in the United States every three hours for issues involving a battery. Most of the cases involve children under 5 and batteries that were swallowed.
These findings are relevant because a swallowed battery can result in severe injury and even death in extreme cases. This issue can be examined by building a Cause Map, a visual format for performing a root cause analysis. In this example, there is the potential for serious injury or death because children are swallowing batteries and batteries can cause serious injuries. More children are swallowing batteries in part because of the increasing popularity of button batteries, which account for 84% of all battery-related ingestions. Button batteries are shiny, circle batteries that are used in a number of modern gadgets and there are far more of them in the typical house today than 20 years ago. They are used to power toys, games, hearing aids, remotes and any number of small things common in the modern household.
Button batteries are more likely to be swallowed than traditional batteries because they are much smaller. It’s also easy to see how the shiny appearance of button batteries would be tempting to small children. Some devices use screws or other restraints on their battery compartments so that children can’t remove the batteries, but many devices do not, especially those intended for adult use.
Button batteries can cause serious injuries because they can get stuck in the esophagus, a moist environment where the battery can form a microcell that erodes the tissue. In the worst cases, the battery can eat though the throat and into the aorta, causing a child to bled to death. Damage can also occur very quickly, in less than two hours and the child may not show any symptoms at first.
The best way to protect children is to tape the battery compartment or securely store all devices that use button batteries if the battery compartment does not have a screw. It is also essential to take children to the emergency room immediately if there is any suspicion that they might have swallowed a battery. A simple x-ray can determine if a battery was swallowed and quick removal of the battery can prevent significant damage if the battery is caught in their esophagus.
Click “Download PDF” above to view a high level Cause Map of this issue.
By Kim Smiley
A new study has found that Amish children living in Indiana have far fewer allergies than the general population and even significantly fewer allergies than other children living on farms. As high as 50 percent of the general population has evidence of allergic sensitivity when tested and only seven percent of the Amish children had allergic sensitivity. The study also looked at Swiss children living on farms and found that they had half the allergic sensitivity of the general population, but still more than Amish children.
Why is this finding significant? Scientists hope that studying the Amish will help them understand what factors are causing the large increase in allergies in the general population in Western Countries over the past few decades.
This issue can be built into a Cause Map, an intuitive, visual root cause analysis, to help illustrate the-cause-and-effect relationship between the factors involved. As more research is done and more information on this issue becomes available, it can easily be added to the Cause Map. In this example, researchers aren’t sure why the Amish have such low levels of allergic sensitivities, but there are a few factors that are likely involved. These factors could be documented on the Cause Map, but a question mark would be added to note that more information is needed to verify the accuracy of the cause and to ensure proper placement on the Cause Map. To view a high level Cause Map of this issue, click “Download PDF” above.
One fact worth adding to the Cause Map is that Amish are exposed to a wide variety of animals and the germs that go along with them from a young age. Many Amish live on farms and nearly all own horses for transportation. Additionally, Amish children help care for the animals from a young age. Pregnant Amish women are also typically around large animals and the prenatal exposure may play a role. Many Amish also consume unpasteurized milk and the impact of this on development of allergies is an ongoing debate.
In addition to environmental factors, some researchers also think that genetic plays a role in allergies so it is also worth noting that the Amish are relatively isolated genetically with limited mixing with the general population.
Understanding the factors that contribute to the low allergy rates of Amish children would hopefully help scientists both understand why allergies in the general population are increasing so dramatically and the best actions to take to treat them, maybe even before they develop.
By Kim Smiley
A new study has determined that it may be possible to develop a blood test to diagnose depression in teens. Finding better ways to treat depressed teens is important because untreated depressed teens are at higher risk for substance abuse, social difficulties, physical illness and suicide. Teens are particularly at risk from depression because this is an age when depression frequently hits and teens can be difficult to properly diagnose and treat.
Currently, the process to diagnose depression is subjective and relies on a patient’s ability to identify and describe symptoms, something that is typically more difficult for teens. Depressed teens are even more likely to struggle with steps needed to receive treatment for depressions. Teens are also typically more worried about others opinions than adults and the fear of judgment from their peers may prevent depressed teens from seeking treatment.
An objective blood test would help simplify the process of diagnosing teens with depression and should help more depressed teens receive appropriate treatment. A straight forward test, like a test for blood sugar or for cholesterol, should also help remove any remaining social stigma of depression treatment so hopefully more affected individuals would seek treatment.
In this study, experimental blood tests were done looking for genetic markers that had been identified in earlier studies using rats. Eleven genetic markers were found that were tied to depression. The researchers were also able to identify which participants had major depression and which suffered from major depression with anxiety. The hope is that a blood test could eventually be used not only to diagnosis depression, but also to differentiate between subtypes of depression, information that would certainly be useful when determining the best course of treatment for patients.
Significantly more work is needed to develop an effective blood test, but this early study hints that it could be possible to create an objective test for depression. This study used a limited number of subjects, 28 teens between 15 and 19 years old, so larger studies will be needed in the future.
This issue can be analyzed by building a Cause Map, a visual root cause analysis. To view the Cause Map, click on “Download PDF” above.
By ThinkReliability Staff
A former member of the US Air Force lost both legs after a routine gallbladder surgery and was medically retired. During the surgery, his aorta was lacerated. Subsequent delays meant his legs were without blood flow for hours.
After the damage to the aortic laceration was repaired, still more time passed before the patient was transferred to a civilian hospital for treatment. The Air Force Medical Center did not have a vascular surgeon on-site. By the time the legs were removed, the patient had lost more than 2/3 of his blood volume.
Multiple issues contributed to the injuries received by the airman. We can examine these issues in a visual root cause analysis presented as a Cause Map. First we determine the impacts to the goals. The patient safety goal was impacted due to the potential for patient death during the surgery and aftermath. Although there was no disciplinary action taken by the Air Force, a $54.8 million lawsuit has been filed that claims negligence. Last but certainly not least, the loss of both of the patient’s legs can be considered an impact to the patient services goal.
We begin with the impacted goals and ask “Why” questions to determine the cause-and-effect relationships that led to the impacted goals. In this case, the patient’s legs had to be removed after they were without blood flow for several hours. The blood loss was caused by a laceration to the aorta, made during the gallbladder surgery, and the subsequent accidental suturing of the aorta during the repair. The repair to the aorta was delayed as it was not immediately recognized. A surgical resident was performing the operation, and it is likely inexperience and lack of supervisor from the supervising surgeon contributed to this delay. Additionally, although the operating room staff was unable to get a blood pressure reading from the patient, it was assumed that the machine was malfunctioning. After the aorta repair, there was further delay in recognizing and treating the loss of blood flow to the legs. As there was no vascular surgeon on-site, the patient was eventually transferred to a civilian facility, where both legs were amputated.
The facility has not commented on the case and so it is unclear what actions might be taken to protect patients. There have been several charges of negligence at the facility in recent years.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.