When a patient at a Chicago-area hospital had to have a portion of his leg amputated, he requested that it be returned to him for burial in accordance with his religious beliefs. The hospital cremated it instead, and the patient has sued the hospital and the hospital rabbi, whom the patient informed of his desires. The lawsuit was dismissed but an appeals court sent the case back for trial.
More information is sure to come out at the trial, but we can begin documenting the information that is known in a Cause Map, or a visual root cause analysis. The Cause Mapping method begins by determining the problem in a problem outline. The what, when and where is captured, as well as the impacts to the goals. This is especially important in a case like this. The patient might claim that the “problem” is that his leg was cremated, while the hospital would probably consider this to be the normal practice of disposed limbs. Instead phrasing the problem as an impact to the organization’s goals (in this case, the hospital’s) agreement can be met. In this case, the compliance goal is impacted because of a lawsuit against the hospital. The patient services goal is impacted because a patient’s requests were not heeded, and because a patient did not understand the release forms presented to him prior to the surgery.
Beginning with an impacted goal, asking why questions will develop cause-and-effect relationships. For example, asking the question “Why were the patient’s requests not heeded?” results in the cause “Patient’s leg was cremated.” The patient’s leg was cremated because there appears to be no procedure for ensuring limbs are saved if requested because typical practice is to dispose of removed limbs. Additionally, the patient signed two release forms which stated the hospital could dispose of the removed portion of the leg.
Clearly the patient did not understand the release forms, as he wanted the leg to be saved, not disposed of. This is another impact to the patient services goal. The patient is legally blind, and so was unable to effectively read the release forms himself. In the lawsuit, the patient claims that the nurse who presented him with the forms explained them as consent forms for surgery and did not discuss that the forms also addressed disposal of the limb that would be removed.
Because the request for the leg was unusual, if the nurse who described the release forms was unaware of the request, it seems understandable that the portion discussing the disposal of the removed limbs (as was done in almost all cases), would not have stood out as something that the patient needed to have summarized. However, this case has raised an issue with summarizing release forms to patients who are not able to read them.
The hospital has not discussed what steps it will take to reduce the likelihood of this type of issue recurring in the future. However, some steps that may reduce the risk are to develop a procedure that would ensure special requests for removed body parts in surgery are followed. Additionally, having release forms read out loud completely for patients who are unable to read the forms themselves would allow those patients to know all of what they are signing.