Monthly Archives: May 2013

Root Cause

11 Patients Killed in Nursing Home Fire

by ThinkReliability Staff

A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia.  At least 11 residents died as a direct result of the fire and nearly 100 were evacuated.    A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)

The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson.   The reasons for the arson are unclear and may never be fully understood.  However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.

We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy.  We begin the analysis with the “What, When and Where” of the event, captured in a problem outline.  Additionally, we capture the impacts to an organization’s goals.   In this case, the patient safety goal was impacted due to the deaths.  There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder.  Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million.  (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.)  Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.

Capturing the  frequency of similar issues can help provide perspective on  the magnitude of nation and world-wide issues.  I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year.  There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.

Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts.  In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility.  The fire initiation, as discussed above, is believed to be due to arson.  However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.

Studies after the event showed how critical sprinklers can be to slow the spread of a fire.  On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016.  It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.

To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.

Root Cause

Concern About a Resurgence of Black Lung Disease

By Kim Smiley 

Did you know that black lung disease has killed 70,000 coal miners since 1970?  Despite regulations designed to protect them, modern coal miners still face very real danger from coal dust.  Changes to the mining industry seem to be exacerbating this long standing issue.

Black lung disease, as coal workers’ pneumoconiosis is colloquially known, is caused by inhalation of coal dust, but there is more to the issue that needs to be understood.  The problem of miners suffering from black lung disease can be analyzed by building a Cause Map, a visual root cause analysis.  Cause Maps lay out the different causes that contribute to an issue visually to illustrate the cause-and-effect relationships.   (To view a high level Cause Map of this issue, click on “Download PDF” above.)

Coal dust is dangerous because it accumulates in the lungs and can cause long-term lung damage and breathing difficulties.  It is irreversible and there is no proven effective treatment.  Death can occur in severe cases.  The only option to fight this disease is prevention.

Black lung disease has a long history and concern about it first came to head in the 1960s.  A strike by 40,000 West Virginia coal miners pushed passage of the Federal Coal Mine Health and Safety Act of 1969.  This legislation limited coal dust exposure to 2 milligrams per cubic meter of air, which was significantly less than most miners were being exposed to at that time.  At first it seemed that the limits were effective in dramatically limiting black lung disease, but some are now worried about a resurgence of the disease.

Some speculate that changes in the mining industry are putting miners at greater risk for black lung disease.  The more dust that miners inhale, the greater the health risk and miners are both working longer hours and using equipment that potentially creates more dust.   The average workweek grew 11 hours since the 1970s which means miners are potentially exposed to dust for hundreds of more hours each year.  Technological advances have resulted in mining technology that is more powerful and can cut through coal faster, which can result in more dust.  The amount of coal produced per hour of work has nearly tripled since the 1970s.  These changes make it more challenging to prevent inhalation of dangerous levels of coal dust.  Increase in demand as well as the rising price of coal has driven these changes because it’s profitable to mine coal as quickly as possible.  Miners are also willing to work in the evolving conditions because mining provides a better living than other jobs available.

One of the most alarming pieces of evidence that cases of black lung may be increasing came from autopsies of the 29 miners killed in the blast at the Upper Big Branch mine in 2010.  The medical examiner was able to test tissue from 24 of the victims’ lungs and he found that 71% of those tested had black lung disease, a truly distressing percentage.  Some of the miners were relatively young and had a limited amount of time on the job.

There is no clear agreement on the best way to prevent black lung disease.  People are still trying to bound the problem and understand how significant the issue is.  But working to understand the problem is always the best first step to trying to solve it.

Root Cause

Health Risks to Young Athletes

By Kim Smiley

Deaths and serious injuries of young athletes make headlines every year.  So how do we ensure that participation in sports is as safe as possible?  The first step is to determine what is causing the deaths and understanding the factors involved.

The serious health risks to young athletes can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map visually lays out all the causes that contribute to an issue to show the cause-and-effect relationships to help illustrate the problem.  According to experts, some of the serious health threats to young athletes are sudden cardiac arrest, heat stroke and concussions.

The potential for concussions, especially in the more physical contact sports, has been getting a lot of attention in the media lately, but the most common cause of death of young athletes is sudden cardiac arrest.  Most cases of sudden cardiac arrest are caused by pre-existing heart conditions and the heart breaking part is that most of these are detectable and treatable.   Most of the heart conditions that cause sudden, unexpected death have few symptoms and can’t be found by a typical sports physical done in the US.  About two-thirds of the dangerous heart defects could be found by an electrocardiogram or EKG test, but these are not routinely done in the US.  The main factor preventing EKGs is the cost, which is not always covered by insurance.  Sudden cardiac arrest is also a risk that many people don’t know a lot about.

Concussions are also a risk for athletes of any age.  Concussions can have long term health consequences and occur when brain cells are damaged.  Concussions are mainly caused by impact to the head, but can also be caused by sudden jolts to the body that cause the brain to hit the inside of the skull.  Impacts during contact sports are a well-known cause of concussions, but typical sports activities like heading a soccer ball can also cause concussions.  Wearing the appropriate safety gear can help prevent concussions.  The rules of some sports also limit the more dangerous plays like helmet to helmet tackles in football.

Another significant risk to young athletes is heat stroke.  Heat stroke is usually preventable, but is still a significant risk and can cause death in extreme causes.  Heat stroke occurs when the internal temperature of the body rises above safe levels.  Young athletes are susceptible to heat stroke because many sports practice outside in hot weather. The typical modern, air conditioned life style increases the risk of heat stroke because athletes are generally less acclimated to the heat at the start of the season.  Athletes are most likely to suffer from heat stroke during the first few days of practice in hot temperatures. Gradually increasing workouts in warm temperatures to allow athletes to acclimate to the weather has been very effective at preventing heat stroke. For example, heat stroke rates dramatically decreased after the NCAA limited practice to three hours once a day for the first five days.

How quickly treatment is administered can also dramatically change the outcomes if an athlete is injured.  Quick action by trained personnel with the appropriate equipment can save lives.  According to a recent New Times Times article, only about 40 percent of high schools in the United States have a certified athletic trainer on staff and only about 70 percent have an automatic external defibrillator (AED).  AEDs are important because they can improve the chance for survival after sudden cardiac arrest by 60 percent or more.

So what is the best way to keep our young athletes safe?  This is a matter of lively debate.  Some people believe that the right answer is to require EKGs during pre-participation physicals, but the cost of performing EKGs on the 7.7 million high school athletes in the US is not trivial.  There is also the issue that EKGs, like most diagnostic tests, are not perfect and produce some false positives that would require more testing that raises costs.  Some believe the money could be better spent by hiring more trainers and buying more AEDs.  The answers aren’t simple, but the better we understand the problem the more informed the decisions will be.

Root Cause

Mom’s Saliva May Boost Infants’ Immune Systems

By Kim Smiley

A recent study found that “cleaning” a baby’s pacifier by sucking on it may actually have some lasting health benefits.  Researchers determined that babies given pacifiers exposed to their parents’ saliva developed fewer allergies.  It’s still not clear whether the benefits come from the actual oral cleaning of the pacifier or if this was just a marker of parents who had a more laid back approach to cleanliness, but scientists are finding increasing evidence that some exposure to more microbes early in life results in fewer allergies.

A Cause Map, a visual format for performing a root cause analysis, can be used to illustrate this issue.  A Cause Map intuitively shows the causes that contributed to an issue as well as the cause-and-effect relationships between them.  In this example, researchers found that infants whose parents cleaned their pacifiers by sucking on them, rather than by boiling or rinsing with tap water, had lower rates of eczema, fewer signs of asthma and smaller amounts of a type of white blood cell that rises in response to allergies.  The key seems to be that saliva contains traces of the parents’ gut microflora.  The infant’s immune system is stimulated by this exposure to their parents’ microflora and this seems to help prevent allergies, which are caused by the immune system responding to harmless inhaled or ingested proteins.  The study also found that children who are delivered vaginally develop fewer allergies than those who are born via cesarean, which limits exposure to bacteria during birth.

These findings are important because the percentage of the population in industrialized nations suffering from allergies has risen rapidly in the 20th century.  Currently, about a third of the children in affluent countries are affected by allergies.  Studies, such as this one, are being done to try and determine what is causing the increase in allergies but the causes are not definitively known yet.  Circumstantial evidence seems to point to lack of exposure to microbes in early childhood as a risk factor.  This study was relatively small and more research on a larger scale will need to be done, but it is beginning to seem that children who get a little dirty and put a few questionable things in their mouths actually benefit from the exposure.

So if you had a mom who cleaned stuff (and you…) with her spit, you have one more reason to thank her this Mother’s Day.  Or if you were that type of mom you have one less reason to feel guilty.

Check out our previous blog – Amish have few allergies

Root Cause

Study Finds that Fukushima Fallout is Affecting Babies in US

By Kim Smiley

A recent study found that babies born on the West Coast of the United States shortly after the Fukushima nuclear reactor meltdown have a higher rate of congenital hypothyroidism than those born a year earlier.  Thyroid issues have long been known to be associated with exposure to radiation and this finding feeds worries about the long term and long distance impact of the reactor disaster.

This issue can be analyzed by building a Cause Map, a visual root cause analysis, which intuitively lays out all the causes that contributed to an issue.  A Cause Map is built by asking “why” questions and adding the answers to the Cause Map to show the cause-and-effect relationships.

Why has the rate of congenital hypothyroidism increased?  This happened because the infants had radioactive iodine in their thyroids and radioactive iodine may affect the functioning of the thyroid if ingested.  If the thyroid doesn’t function properly, it can’t make the necessary hormones for healthy development and both growth and development can be stunted. The impacts of radioactive iodine are predominantly seen in the thyroid because ingested iodine concentrates in the thyroid where it is used to produce hormones.  The body can’t distinguish between stable and radioactive isotopes of iodine and it will store whatever iodine is available so ingested radioactive iodine can be kept within the body long enough to cause damage.

In the cases of fetuses, the mother passes iodine to her baby.  If pregnant woman ingests radioactive iodine, some of it will likely end up in the thyroid of her baby who needs the iodine to develop properly.  In this example, pregnant women on the West Coast were exposed to significantly higher than normal levels of iodione-131 following the Fukushima meltdown. Iodione-131 is a fission product that is created in a nuclear reactor when atoms are split.  When the reactor containment failed, radioactive isotopes of iodine were released into the environment along with other fission products.  Winds carried some of the radiation across the Pacific Ocean. Iodine-131 concentrations in precipitation in the United States were up to 211 times above normal in the days following the accident.  Some of this radioactive iodine found its way into the food supply and was ingested by people, some of them pregnant women causing the increase in cases of congenital hypothyroidism.

The good news is that congenital hypothyroidism with can be treated if found early.  The bad news is that there may be more health issues from the Fukushima meltdown in places outside of Japan discovered in the future.  The reality is that more than two years after the event we still don’t know what all the impacts of the radiation will be, both in Japan which has obviously suffered the most and in other countries.