Monthly Archives: January 2014

Root Cause

Man Found Dead After Waiting 8 Hours for Emergency Treatment

By ThinkReliability Staff

A man seeking treatment for a rash at a Bronx hospital emergency room (ER) was found dead eight hours later, still in the waiting room, of as-yet unknown cause.  The incident is currently under investigation by the New York State Department of Health and the cause of death will be determined by a medical examiner.

When performing an investigation of a case like this one, it’s important to focus on the goals that were impacted by the incident and determine all the causes that resulted in the goals being impacted, not just finding one “root” cause.  In this case, the impact to the patient safety goal has clearly been impacted because of the death of a patient within the hospital itself waiting to be seen.  The patient service goal was clearly impacted because the patient did not see a doctor in the six hours – or more – between arrival and his death.  The schedule goal is impacted by the significantly higher-than-average wait at this particular ER.  Lastly, the labor goal appears to be impacted by insufficient staffing levels.

According to the hospital, the cause of the patient’s death is simple.  Per the Hospital spokesperson: “His name was called several times on several occasions, and he did not respond… People have personal responsibility when your name is called, you have to get up and see the doctor.”  The hospital says that all guidelines were met and, even goes so far to add that “probably this scenario in this shape and form has happened in any big hospital in New York City.”

Many don’t find that answer acceptable. Although hospital guidelines may have been followed, there’s no discussion of whether the guidelines were adequate.  It is apparent that the hospital guidelines do not include any sort of care or supervisor for patients prior to being called in to the waiting room.  However, there’s no discussion of whether that meets the standard of care expected of these hospitals.  As this lack of oversight resulted in the death of a patient going unnoticed – potentially for hours – in a hospital waiting room.

In addition, the incident has brought up questions about the impact of the long wait time.  The wait at the emergency room for this hospital is an average of 306 minutes – more than 5 hours.  The national average is 137 minutes and the average in the state of New York is 155 minutes.  When the patient was called, starting at 2 and a half hours after entry, he may have well been asleep, given that the next interaction he had was with a security guard who woke everyone in the waiting room at 2 a.m.  This periodic waking of people in the waiting room – meant to ensure that nobody was using the waiting room as a shelter – next happened at 6:40 AM, and is when the patient was found dead.  Unofficial reports suggest the patient may have been dead for hours.  The patient was last seen moving at 3:45 AM on security cameras.

These questions demonstrate the fallacy of the one “root” cause approach.  The hospital’s assessment begins – and ends – with placing blame on the patient for not responding to a call in the ER.  But this expectation may not be appropriate in all cases.  Although a shorter ER wait time may or may not have saved the life of the patient in this case, it would certainly ease the strain of an ER visit for most patients and potentially save a life.  There have been several publicized cases of deaths or significant disabilities resulting from waiting too long in the ER.  Certainly an incident like this occurring at a hospital merits a review of policies that allowed a man to die unnoticed by staff.

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

Root Cause

Inappropriate Antibiotic Risk Not Decreasing for Adults

by ThinkReliability Staff

Infections caused by bacteria (such as sinusitis and tonsillitis) respond to antibiotics; those caused by viruses (such as bronchitis and influenza) do not.  Prescribing antibiotics for viral infections will not treat the infection and contributes to the rise of antibiotic-resistant bacteria. This is known as inappropriate antibiotic use.   A recent study showed that efforts to reduce inappropriate antibiotic use have been effective in pediatric, but not adult, patients with acute respiratory tract infections.

To thoroughly understand the issue, we consider both the effects and causes of inappropriate antibiotic use.  A cause-and-effect diagram, or Cause Map, visually lays out these cause-and-effect relationships.

The effects of the issue are captured in a problem outline.  Effects are captured with respect to an organization’s goals.  In this case, the impacted goals are wide-ranging, so we look at them from a general health industry perspective.  Unnecessary antibiotic use can impact the person to whom they are prescribed, which impacts the patient safety goal. Unnecessary antibiotic use also increases antibiotic resistance, a growing public health problem with no easy answers.  This can be considered an impact to the public safety goal.  (For more information, please see our previous blog about antibiotic resistant bacteria and fungus.)

Besides patient and public health safety concerns, unnecessary use of antibiotics can result in unnecessary cost.  A program at a University of Maryland hospital that monitored antibiotic use resulted in $3 million in annual savings with no impact to care quality.  However, when the program ended, so did the savings.

In addition to capturing the impact to the goals in the problem outline, we can capture general information about the issue being analyzed, including important differences.  These differences can provide valuable information about potential causes to be evaluated.  An interesting difference noted in the study is that efforts to reduce unnecessary antibiotic use were effective for pediatric patients but not adults.  So far, the reason for the difference in pediatric and adult use has not been determined, but a decrease in inappropriate antibiotic use for children is a positive step forward.  (And not just because of antibiotic resistance.  A 2012 study found that antibiotic use in infants can lead to obesity.  Click here to learn more.)

After the effects of an issue are determined, cause-and-effect relationships that will lead to the causes of an issue can be developed by asking “why” questions.  In this case, several possible causes for inappropriate antibiotic use have been suggested.  Identifying causes allows more opportunities for solutions to address these causes.

Perceived pressure from patients to receive an antibiotic when presenting to the emergency room for an acute respiratory infection and difficulty making a definitive diagnosis to determine whether the infection is viral or bacterial are two of the reasons given for the continued inappropriate use of antibiotics.  Patient education can help.  A review of 89 studies in 19 countries found that prescriber access to education and advice or restrictions on prescribing antibiotics have been effective in reducing inappropriate antibiotic use.

A surprising increase in the use of antibiotics appears to be due to a reduced out-of-pocket cost borne by patients.  After Medicare Part D went into effect, reducing drug costs for some patients, a study found increases in antibiotic use for acute respiratory infections.  The study suggested that changes in patient cost-sharing may be effective in reducing unnecessary antibiotic use.

It’s likely that a combination of causes will be needed in order to reduce the prescribing of unnecessary antibiotics to a minimal level that can aid in the fight against antibiotic resistance.  Ideally, further studies will be able to develop lessons learned from the successful pediatric programs that have reduced inappropriate antibiotic use so they can be implemented for adult patients as well.

To view the Outline and Cause Map, please click “Download PDF” above.

Root Cause

The Willie King Case: Wrong Foot Amputated

By Kim Smiley

In one of the most notorious medical error examples in US history, the wrong foot was amputated on a patient named Willie King on February 20, 1995.  Both the hospital and surgeon involved paid hefty fines and the media had a feeding frenzy covering the dramatic and alarming mistake.

So how did a doctor remove the wrong foot?  Such a mistake seems difficult to comprehend, but was it really as mind boggling as it looks at first glance?

The bottom line is that the doctor honestly believed he was removing the correct foot when he began the surgery. The blackboard in the operating room and the operating room schedule all listed the wrong foot because the scheduler had accidentally listed the wrong foot.  After reading the incorrect paperwork, the nurse prepped the wrong foot.  When the doctor entered the operating room, the wrong foot was prepped and the most obvious documentation listed the wrong foot.  Basically, the stage was set for a medical error to occur.

The foot itself also looked the part.  The patient was suffering from complications of diabetes and both of his feet were in bad shape.  The “good” foot that was incorrectly removed looked like a candidate for amputation so there were no obvious visual clues it wasn’t the intended surgery site. Other doctors had testified in defense of the doctor saying the majority of other surgeons would have made the same mistake given the same set of circumstances.

There was some paperwork that listed the correct foot to be amputated, such as patient’s consent form and medical history.  This paperwork was available in the operating room, but no procedures in place at the time required the doctor to check these forms and these forms were far less visual than the documents where the incorrect information was listed.  Additionally, the doctor never spoke directly with the patient prior to the surgery which was another missed opportunity for the mistake to be caught.

Clearly the procedures needed to be changed to prevent future wrong site surgeries from occurring and a number of changes have been incorporated in the time since this case occurred to help reduce the risk of this type of medical error.  Surgeons in Florida are now required to take a timeout prior to beginning a surgery.  During the time out they are required to confirm that they have the right patient, right procedure and right surgical site.  This rule has been in place since 2004.

Mistakes will always happen, such as numbers being transposed or misheard words over the phone, but small mistakes need to be caught before they become big problems. Procedures like a timeout can significantly reduce the likelihood of an error going uncorrected.  In an ideal world, the simple mistake by the scheduler would have been caught long before it culminated in a surgery on the wrong body part.

A visual root cause analysis, called a Cause Map, can be built to illustrate the facts of this case.  A Cause Map intuitively lays out the cause-and-effect relationships including all the causes that contributed to an issue.  To view a Cause Map of this example, click on “Download PDF” above.

Root Cause

Patient Dumping Has Dangerous Results

By ThinkReliability Staff

“Patient dumping”, when hospital patients are improperly discharged, sometimes to dangerous areas, or even out of state, and sometimes without proper instructions for care, is a serious risk to patient safety and health and can result in serious costs for the hospitals and people involved.  In a recent case, a California hospital made a settlement for $250,000 in civil penalties and legal fees for leaving a patient at skid row without making any arrangements for her.

This case – and others like it – lead to obvious concerns for the health and safety of these patients.  That’s led city attorneys and homeless advocates to crack down.  Operators of homeless shelters and rescue missions in the area have installed “dump cams”, which allow them to identify cases where patients are being “dumped”.  In Los Angeles, the police department has stated they will arrest anyone who leaves patients outside a shelter.  And Mike Feuer, a city attorney, says, “Patient dumping is intolerable to me. I do have it in my mind to send a message to other hospitals that this won’t be tolerated.”

Although patient dumping appears to have lessened in recent years, it’s still a real problem.  In other newsworthy cases, another Los Angeles hospital settled a group of charges in 2011 when it discharged a disoriented patient – still in her hospital gown – by taxi and she was left in the street.  Yet another area hospital was sued for negligence in 2012 when it left a patient being treated for schizophrenia outside a rehabilitation center without notifying the patient’s family.  In 2013, the city of San Francisco filed suit against the state of Nevada, saying that a psychiatric hospital had issued bus tickets to California cities for mentally ill patients without making arrangements for them.

Even though the risks to patients are apparent (and financial costs to hospitals are possible), these problems continue to occur.  In cases where organizations don’t seem successful at ensuring the safety of its patients (or employees), the government will step in.  In this case, Los Angeles in particular has implemented a “patient safety zone” which encompasses most of the city’s downtown, where it is illegal to leave patients unless they are in the care of a family member.  Additionally, hospitals must obtain written consent from patients to take them to a place other than their home.

This of course can be tricky when dealing with homeless, mentally ill, or patients without relatives living nearby.  Although patient resources when dealing with these cases are limited – making proper discharge difficult in some cases – leaving a patient alone in an unfamiliar, dangerous area is never the right answer.

The impacted goals resulting from patient dumping, some potential causes, and the solutions that have been implemented by the city of Los Angeles are shown in a Cause Map, or visual root cause analysis.  To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

27 Patients to be Tested After Ultrasound Probe Sterilization Error

By ThinkReliability Staff

On December 21, 2013, 27 men were notified that, due to improper sterilization of equipment used for their prostate procedures, they should be tested for HIV and hepatitis B and C.   Both the medical center and patients involved are understandably concerned about how they got to this point.

In order to better understand the issues involved, we can put together an investigation file using Cause Mapping, a visual form of root cause analysis.  First, we capture the basic information about the issue.

The procedures were performed from September 19 to December 10 of this year at a Seattle medical center and involved ultrasound probes used for prostate procedures.  Because more than one date is involved, we can use a timeline to add more detail to the investigation.  In this case, patients were found to have been affected beginning September 19 and ending December 10, though it’s not clear if the incorrect sterilization began on that date, or if that was the first date that a probe was used on a patient with a communicable disease.  The improper sterilization was reported to hospital officials December 17 and affected patients were notified beginning December 21st.  As a result of information released by the medical center, we know that one step in the sterilization process for the probes was not completed.  We capture this as an important “difference” that may aid in the analysis.

Next, we determine the goals that were impacted as a result of the issue.

The patient safety and patient services goals were impacted due to the risk of disease transmission for the 27 patients (the probability of which is estimated to be very low).  The compliance goal is impacted because of equipment that was not sterilized as required.  The labor goal is impacted because the medical center is paying for two rounds of HIV and hepatitis testing for the affected patients.  If it is determined over the course of the investigation that other goals were impacted as well, these can be captured in the Problem Outline as well.

Once we have determined the impacted goals, we use these goals as the first “effect” to determine the cause-and-effect relationships that resulted in the issue.  In this case, the patient safety and services goals were impacted due to the risk of disease.  The disease risk resulted from the reuse of prostate probes that had the possibility to spread disease.  The disease risk occurred because the probes may have been used on a patient that had a communicable disease and the probes were not properly sterilized before their reuse.

We can show the steps that should have occurred in the sterilization process of these probes, as well as where the specific issue in the process occurred, in a Process Map.  This map shows the steps involved in a procedure, in this case the ultrasound probe sterilization procedure.  After a probe is used, it goes through a three-step process, involving cleaning, disinfecting or decontaminating with a disinfectant spray, then sterilization by being doused with sterilization fluid.  Then the sterilized equipment is placed in a protective sheath before re-use.  (Because of the use of this protective sheath, the probe, when properly used, does not contact the patient, decreasing the risk of disease transmission.)  In this case, the sterilization step was not performed.

We include the fact that the procedure was not performed properly in the Cause Map.  The Chief Medical Officer reports that their investigation found that the cause was “human error” and no more information has been released.

In order to determine effective solutions to prevent the issue from recurring, more detail needs to be obtained about the expectations for the process being performed, as well as the verification (if any) that took place to ensure that the procedure was being performed correctly.  Once it’s possible to determine what allowed the process to break down, safeguards that will reduce the risk of it happening again can be implemented.

To view the initial investigation file, including the Outline, Cause Map, Timeline and Process Map, please click “Download PDF” above.