By Kim Smiley

A teen, who was 17 at the time, was arrested on September 2, 2012 for impersonating a physician’s assistant in a Florida hospital.  The young man worked at a hospital, treating patients and performing duties typical of a physician’s assistant, for about a week before anyone became suspicious of his lack of credentials.  Investigation into the case found that he examined patients, removed an IV and even performed CPR without any medical training.

How could this possibly happen?  A Cause Map, or visual root cause analysis, of this situation can be built to help understand the different causes that contributed to a young man successful impersonating a medical professional.  The first step in building a Cause Map is to determine how the issue impacted the overall organization goals.  In this example, the safety goal is clearly impacted since an unlicensed individual treated patients.  The customer service goal was also impacted because of the negative publicity for the hospital involved in the scandal.

Causes are added to the Cause Map by asking “why” questions.  Why did this happen?  How did a teen end up performing the duties of a physician’s assistant?  Statements by the teen indicated that he was interested in learning more about the profession so he decided to work at the hospital.  He was able to pull this off because he was incorrectly given a physician’s assistant identification badge and nobody initially questioned his credentials because he acted the part well.

The teen worked as a clerk in a doctor’s office near the hospital and when he went to the ID office to get a badge, he was somehow given the wrong one.  His credentials were never checked and personnel at the ID office have stated that this was because the office was very busy at the time.  The teen also never told anybody he had the wrong badge and decided to use it.

The masquerade was also successful for a time because the teen played the role of physician’s assistant well.  He wore scrubs and a stethoscope and used the correct terminology.

This case went to trial in August 2012.  The teen was found guilty on two counts of impersonating a physician assistant and two counts of practicing medicine without a license.  His sentencing is scheduled for November 14 and he faces up to 25 years in prisons.

To view a high level Cause Map, click “Download PDF” above.