Monthly Archives: July 2012

Root Cause Analysis

The Low Survival Rate of Pancreatic Cancer

By Kim Smiley

Sally Ride, the first US woman in space and a national hero, died after a 17-month battle against pancreatic cancer on July 21, 2012.  Pancreatic cancer is a particularly deadly cancer with only a 6% five-year survival rate.  This disease also affects many people.  In 2010 alone, an estimated 43,000 people in the US were diagnosed with pancreatic cancer.

The reasons that pancreatic cancer is so deadly can be explored by building a Cause Map, a visual root cause analysis.  The first step in building a Cause Map is outlining the problem which includes defining how the problem impacts the organizational goals.  In this example, the primary goal considered is the impact to the safely goal since pancreatic cancer has such a low survival rate.

In order to build the Cause Map, “why” questions are asked and the answers are added to the Cause Map.  Why does pancreatic cancer have such a low survival rate?  The survival rate is low because the cancer has usually spread beyond the pancreas by the time it is detected and pancreatic cancer is difficult to treat.  The cancer has typically spread before detection because there are very few symptoms in the early stages of the cancer and any symptoms that do exist are usually vague, like aches and pains that could easily be attributed to other illnesses.  There is also no screening test like there are for breast or prostate cancer to detect pancreatic cancer at this time.

Pancreatic cancers are difficult to treat for several reasons.  First, pancreatic cancers are resistant to chemotherapy.  The best course of treatment is typically removal of the tumor, but many cases are caught too late for the tumor to be removed because the cancer has usually spread by the time it is detected.

Researchers are working on improving the survival rate for pancreatic cancer.  There are some promising studies that show it may be possible to develop a screening test that could detect pancreatic cancer at earlier stages, which could significantly improve the chances for survival.

To view a high level Cause Map of this issue, click on “Download PDF” above.

Root Cause Analysis

Delay in Treatment for Sepsis Results in Death of a Child

By ThinkReliability Staff

On April 1, 2012, a patient at a university medical center in New York died from sepsis.  The death was especially heartbreaking as the patient was 12 years old . . . and had been healthy just 4 days prior.  However, he had contracted a bacterial bloodstream infection (sepsis), which has a high mortality rate (nearly 40%, according to the United Hospital Fund) that grows with every passing hour.  (A study cited by the New York Times found that the survival rate decreases by 7.6% every hour before antibiotics are given.)  With response time so crucial to patient outcome, rapid action at every step of the process is required.

We can look at this incident in a visual root cause analysis, or Cause Map.  The purpose of this map is not to assign blame, but rather to discover and document causes in the hope of finding solutions to reduce the occurrence of this type of issue.

We begin with the impacts to the goals.  In this case, the patient safety goal was impacted due to a patient death.  Because of the high potential for emotional impact to providers, employees are also impacted.    The potential for a lawsuit is an impact to the organizational goal, and the initial misdiagnosis of the patient is an impact to the patient services goal.

We begin with the patient safety goal and ask “Why” questions to develop cause-and-effect relationships that will show all the causes of the incident.  The patient died of severe septic shock and insufficient intervention.  (Had intervention come earlier, the patient may have lived.)  The onset of the sepsis appears to have been a cut acquired at school, which was bandaged, but possibly not cleaned, likely due to the lack of severity of the initial injury.  Delay of treatment allowed the sepsis to overwhelm the immune system.  The treatment was delayed due to an initial misdiagnosis of dehydration.     Sepsis is particularly difficult to diagnose because many of its symptoms mirror symptoms of other more common ailments.  Information was not shared between providers – the child’s primary care pediatrician, parents, and the hospital staff, which may have contributed to the difficulty in diagnosis.  Test results taken at the hospital came in after discharge and were not shared by phone with the primary provider or parents.  Additionally, even after lab results from the hospital suggested that the white blood cell count was abnormally high, indicating infection, no action was taken.

From this very basic, high level map, at least four areas of specific improvement can be noted.  Protocol at the school for injuries that involve cuts – even if they seem minor – should include cleaning or disinfection.   The hospital should have – and follow – protocol for that specifies action to be taken upon receipt of lab results.   This protocol should include documenting and sharing test results with other providers and caregivers.  Because of the difficulty in diagnosing sepsis, and the importance of quick action, the United Hospital Fund is current developing a STOP Sepsis Collaborative, which aims to “reduce mortality in patients with severe sepsis and septic shock by implementing a protocol-based approach to case identification and rapid treatment”.  Ideally, implementation of the results of this collaborative will reduce the risk of patient death from a situation like this tragic case.

To view the Outline, event Timeline, Cause Map, and Solutions, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis

Accidentally Ingested Wire Bristles

By Kim Smiley

There have been a number of documented cases of people accidentally swallowing wire bristles from the brushes commonly used to clean grills.  If ingested, the bristles can cause significant pain and have the potential to puncture organs, including the intestine which can lead to dangerous infections.  There isn’t a lot of data available to determine how often this occurs, but a recent report discussing six cases of ingested wire bristles at a single hospital in a one year period hint that this may be more common than many realize.

This issue can be analyzed by building a Cause Map or visual root cause analysis.  The first step in creating a Cause Map is to determine how the issue impacts the overall goals of an organization.  In this example, we’ll consider the organization the general public and the main impacted goal is the safety goal since there is a risk of serious health issues.  Causes are now added to the Cause Map by asking “why” questions.  Why is there a risk of serious health issues?  Because there is the potential to swallow a wire bristle and the wire bristle can do a lot of damage within the body.   (To view a high level Cause Map of this issue, click “Download PDF” above.)

Continuing the “why” questions, we would now ask “why” is there a potential to swallow a wire bristle?  This possibilities exists because people may inadvertently swallow the bristles without realizing it, the bristles come from wire brushes that are often used to clean residential grills and the bristles sometimes fall out of the brushes and stick to the grill.  People may inadvertently ingest the bristles because the bristles can stick to meat and the texture can hide the presence of the bristle.  Many people are also unaware of the potential danger of eating a wire bristle so they aren’t looking to find bristles.  Investigation into this issue has not found any defects that are causing bristles to fall out.  No one brand or type of grill brushes has been singled out as the culprit in these causes, but a worn grill brush is more likely to shed bristles than a new brush.

All six patients in the report did make full recoveries after treatment.  In three of the cases, the wire bristles were stuck in the throat and required only laryngoscopic removal; the other three cases required more invasive surgery to remove the object.

The best way to protect yourself from the possibility of this occurring is to inspect the grill after using a wire grill brush or to find another method to clean your grill.  The Consumer Product Safety Commission has asked that medical professions or consumers report any incidents of swallow grill brush bristles to http://www.saferproducts.gov to help monitor this issue.