Monthly Archives: October 2015

Root Cause Analysis

Handwashing is effective at fighting disease – so why doesn’t it happen more?

By ThinkReliability Staff

Global Handwashing Day is October 15. It’s very clear that handwashing can prevent disease – one study showed that it resulted in a 30% reduction in episodes of diarrhea; another study showed it could reduce the risk of respiratory infections by 16%. Yet proper handwashing is still not happening in many places. It’s estimated that the rate of handwashing is less than 20% in some developing countries.

There are multiple reasons that effective handwashing may not be occurring. We can look at these issues, as well as some of the solutions that have been suggested or implemented to increase the rates of handwashing, in a Cause Map, or visual root cause analysis. This method, like other problem-solving methods, involves three steps to define the problem(s), analyze the issues that may cause the problems, and brainstorm solutions that will reduce the risk of the problem(s) recurring.

In Cause Mapping, the problem is defined as the impact to an organization’s goals. In this case, the goals are broad and impact the population of most of the world. The risks of increased disease (particularly diarrhea and respiratory infection) impact the public safety goal. Contamination of handwashing water is an impact to the environmental goal.

The cause-and-effect analysis begins with the impacted goals. Asking “why” questions allows us to determine the causes that resulted in the impacted goals (or effects). It has been established (by the previously mentioned studies, as well as others) that the public safety impacts of increased risk of disease result from ineffective handwashing (or no handwashing at all).

Proper handwashing involves 3 things: clean water, soap, and time. Lathering with soap for about twenty seconds detaches oils and microbes from the skin and water washes it away. Removing any one of these things results in an ineffective wash, and there are multiple reasons why this could occur.

If no soap is available, washing won’t be able to remove disease-causing microbes. Obtaining soap may be difficult due to cost or availability. If soap is obtained, it may be eaten by goats (seriously, goats eat everything) or may not be used if it doesn’t smell good. Solutions suggested include making a protective cover to protect the soap from goats, finding less expensive soap supplies, or creating hand soap out of laundry soap and water. Hardening soap in the sun can help it last longer. Some groups have also started developing nicer-smelling, inexpensive soap or allowing donation of leftover pieces of soap from hotel use.

Even with soap, washing for a period of time (about twenty seconds) is required to give it time to fully remove germs and oils. Various versions of handwashing jingles (songs about the importance of handwashing that last at least the required amount of time) have been developed and are being spread across many areas of the world.

Lastly, even if handwashing involves lathering with soap for at least twenty seconds, if the soap is then rinsed off using contaminated water, the contamination will spread to the just-washed hands. In areas where there is no running water, water used for handwashing can be contaminated when dirty hands or ladles are dipped into the water. To reduce the risk of contamination, many areas use plastic containers that contain a tap that drips out water to use for handwashing.

Even with these difficulties, handwashing remains the most effective, inexpensive way to prevent disease across the globe. No matter where you live, it’s important to wash your hands properly and frequently, to fight the spread of disease.

To view the Cause Map and solutions related to this issue, click “Download PDF” above. Or, click here to read more.

 

Root Cause Analysis

Lethal-Injection Drug Mix-up

By ThinkReliability Staff

On January 15, 2015, a prisoner was executed by lethal injection in Oklahoma. On October 8, the autopsy report, showed that prisoner had been injected with potassium acetate instead of potassium chloride as intended.

This was the first injection to take place in the state since a prisoner took 43 minutes to die after the drugs were administered in April 2014 (see our previous blog about this execution).  After that, further executions were stayed.

Just hours prior to the first execution scheduled since January, Department of Corrections personnel realized they were sent potassium acetate instead of potassium chloride and that execution was called off.  Shortly afterwards, an Oklahoma court granted an indefinite stay for the prisoners who were scheduled for execution.

While there is ongoing debate about whether the change adversely impacted the speed or humaneness of the execution, it certainly caused great concern about the ability of the state of Oklahoma to correctly perform an execution.  Says an attorney, “The state’s disclosure that it used potassium acetate instead of potassium chloride during the execution of Charles Warner yet again raises serious questions about the ability of the Oklahoma Department of Corrections to carry out executions.”

Along with the concern for ability to perform future executions, there is potential safety impact regarding the prisoner’s suffering, as well as the production impact resulting from the delay in future executions.  The ongoing investigation will also impact goals because of the resources required.  This investigation will attempt to determine how the wrong drugs were used in the execution.

In case of the execution scheduled for September, the wrong drug was placed in the syringe used to inject the prisoner, and there was an ineffective verification of the drugs.  It’s unclear whether there was an attempt at verification that the drugs being used were correct.  If there was such a check, verification may have been difficult because records show that the syringe was labeled potassium chloride (the desired drug).

Department of Corrections records also show that the state received potassium acetate instead of the desired potassium chloride.  It seems that the potassium acetate was accidentally delivered from the supplier (there doesn’t appear to be a need for potassium acetate).  According to the prisons director, the supplier believed that the drugs were interchangeable.  In general, the oversight of suppliers who provide lethal injection drugs is limited – many states refuse to disclose their suppliers and many suppliers are compounding pharmacies, which are subject to less regulation.

Oklahoma does have several different combinations and substitutions of drugs allowable for executions, but there is no approved substitute for potassium chloride.  This, and recent changes to suppliers because so many refuse to supply drugs for lethal injection, may have led to some confusion.

It’s likely that solutions, or changes to the execution protocol may not be discussed until after the investigation is complete.  A completely different type of execution may be considered: in April 2014 Oklahoma approved nitrogen gas the backup method for executions if lethal injection could not be used.  Based on all the recent issues and concerns, that new method may be under consideration.

Root Cause Analysis

Why You Will Experience a Diagnostic Error

By ThinkReliability Staff

On September 22, 2015, the Institute of Medicine released a report entitled “Improving Diagnosis in Health Care“. The report was the result of a request in 2013 by the Society to Improve Diagnosis in Medicine to the Institute of Medicine (IOM) to undertake a study on diagnostic error. The tasking to the committee formed by the IOM matched the three step problem-solving process: first, to define the problem by examining “the burden of harm and economic costs associated with diagnostic error”; second, to analyze the issue by evaluating diagnostic error; third, to provide recommendations as “action items for key stakeholders”.

The burden of harm determined to result from diagnostic errors is significant. Diagnostic errors are estimated to contribute to about 10% of hospital deaths, and 6-17% of hospital adverse events, clearly impacting patient safety. Not only patient safety is impacted, however. Diagnostic errors are the leading type of paid malpractice claims. They also impact patient services, leading to ineffective, delayed, or unnecessary treatment. This then impacts schedule and labor as additional treatment is typically required. The report found that, in a “conservative” estimate, 5% of adults who seek outpatient care in the United States experience a diagnostic error each year and determined that it is likely that everyone in the US will likely experience a meaningful diagnostic error in their lifetime.

The report also provided an analysis of issues within the diagnostic process (to learn more about the diagnostic process, see our previous blog) that can lead to diagnostic errors. Errors that occur at any step of the diagnostic process can lead to diagnostic errors. If a provider receives inaccurate or incomplete patient information, due to inadequate time or communication with a patient, compatibility issues with health information technology, or an ineffective physical exam, making a correct diagnosis will be difficult. Ineffective diagnostic testing or imaging, which can be caused by numerous errors during the process (detailed in the report). Diagnostic uncertainty or biases can also result in errors. However, not all errors are due to “human error”. The report asserts that diagnostic errors often occur because of errors in the health care system, including both systemic and communication errors.

When diagnostic errors do occur, they can be difficult to identify. The data on diagnostic errors is sparse due to both liability concerns as well as a lack of focus historically on diagnostic errors. In addition, there are few reliable measures for measuring diagnostic errors, and diagnostic errors can frequently only be definitely determined in retrospect.

The report identifies eight goals for improving diagnosis and reducing diagnostic errors that address these potential causes of diagnostic errors. These goals are presented as a call to action to health care professionals, organizations, patients and their families, as well as researchers and policy makers.

To view a high-level overview of the impacts to the goals, potential causes and recommendations related to diagnostic error presented in a Cause Map, or visual root cause analysis, click on “Download PDF” above. To learn more:

To read the report, click here.

For an overview of the diagnostic process, click here.

For an example of a diagnostic error with extensive public health impacts, click here.

Root Cause Analysis

Understanding the diagnostic process is the first step towards improving diagnosis in health care

By ThinkReliability Staff

On September 22, 2015, the Institute of Medicine (IOM) released a report entitled “Improving Diagnosis in Health Care“. To achieve that goal, the committee, “developed a conceptual model to articulate the diagnostic process, describe work system factors that influence this process, and identify opportunities to improve the diagnostic process and outcomes.”

With a goal of improving a given process – in this case, the diagnostic process – it’s important to understand how the process should work in theory (which may be very different from how the process actually works in practice). The conceptual model outlined within the report provides an overview of the theoretical diagnostic process at several different levels of detail.

A Process Map is similar to a geographical map in that it can provide different levels of detail while remaining accurate. For example, a map of a country as a whole typically contains only the most major roads, a map of a city will contain far more roads, and an inset providing detail of a section of the city may contain all the roads. All these maps are accurate; but the city map contains more detail than the national map.

Similarly, an overview of the diagnostic process can be summarized in just four steps: patient reporting of a health problem, information gathering and analysis, diagnosis, and treatment. By adding more detail to this process, the responsive nature of the process is revealed – if sufficient information is not gathered to make a working diagnosis, the process returns to the information gathering step. A similar “decision point” is made after treatment – if treatment is found to be ineffective, the process again returns to the information gathering step for another look at the diagnosis.

Even more detail can be provided about the information gathering step. Information gathering typically involves a clinical history/ interview, a physical exam, diagnostic testing and/or imaging, and referral or consultation with other health care professionals. As the information gathering step can be broken down into more detail, so can the diagnostic testing/ imaging step. In more detail, the diagnostic testing/ imaging step involves ordering diagnostic tests and/or imaging, preparation and collection of the specimen/image, examination of the specimen/ image, result interpretation, follow-up, and incorporating the results into the patient’s medical record. (Because of the similarities at a high level between the diagnostic testing and diagnostic imaging processes, they have been combined in the Process Map on the PDF, but a more detailed process would have separate steps for each.)

When analyzing a complex process, such as the diagnosis process, breaking it down into steps allows for an analysis of problems that occur at each step. Next week, our blog will discuss in more detail the impacts from diagnostic error, potential causes of diagnostic error, and the recommendations from the IOM report to improve diagnosis and reduce diagnostic error.

To view the diagnostic process map at several levels of detail, click on “Download PDF” above. Click here to read the Institute of Medicine report “Improving Diagnosis in Health Care.”