All posts by Angela Griffith

I lead comprehensive investigations by collecting and organizing all related information into a coherent record of the issue. Let me solve a problem for you!

Patient Discharged Alone, Without Being Treated

By ThinkReliability Staff

A patient with schizophrenia and dementia was discharged from a New York City emergency room alone and without effective treatment. Less than two hours after her discharge, she was taken via ambulance to another hospital, which performed emergency surgery on a perforation in the digestive tract. However, because of various communication issues, the family was not notified of her whereabouts until three days later.

Multiple factors were involved in this issue. To provide some clarity about what happened, and where the investigation should go next, we can put the information that is known into a Cause Map, or visual root cause analysis. The Cause Map can be expanded as more information is known.

The first step of any problem investigation is to determine what problem needs to be solved. Rather than attempting to define a complex issue as just one “problem”, the problem is defined as the impact to an organization’s goals. In this case, patient safety was impacted due to the risk of injury to the patient. The regulatory goal is impacted due to the risk of a lawsuit or other regulatory action. Patient services were impacted because of the improper discharge. Additionally, the labor/ time goal is impacted because of an investigation, which the “first” hospital (or regulatory agency) should be performing, although the hospital has not released any information, citing privacy concerns.

The second step of a problem investigation is the analysis. We begin the analysis with one of the impacted goals. To develop the cause-and-effect relationships that make up the Cause Map, we ask “why” questions. In this case, the patient safety goal was impacted because of the risk to the patient. The risk was caused by being discharged alone, and also by being discharged without proper treatment. Because both of these causes resulted in the impact, they are joined with an “AND”. The patient was discharged improperly based on a decision to discharge the patient. Because the first hospital has not released any more details, we have to end that line of questioning with a “?”. However, once the causes related to the patient being improperly discharged are determined, solutions that will improve the discharge process to reduce the risk of other patients being improperly discharged can be brainstormed and implemented.

To ensure the analysis is complete, the other impacted goals must also be addressed. In this case, the labor/ time goal is impacted by the investigation. The investigation results from the patient being discharged improperly (also an impact to the patient services goal) and the hospital’s delay in notifying the family of the patient’s whereabouts. The second hospital did not have the family’s contact information because it was unable to receive it from the first hospital. This is another area that will need to be investigated further. Although the second hospital treated the patient after deeming it was an emergency, the second hospital had no way of contacting the patient’s family. This is particularly important in this case as the patient’s son was designated to make medical decisions for her. Additionally, even though the second hospital notified the first hospital it was treating the patient on the day the patient went “missing”, the first hospital, despite frequent contact with the patient’s family, did not pass that information along until three days later. The communication breakdowns at the first hospital must be addressed.

The third step of a problem investigation is to determine solutions to reduce the risk of similar issues recurring. In this case, more detail is needed about the discharge and communication processes. The solutions will ideally improve those processes to ensure that discharges and communication about patients are made following proper protocol.

To view the initial problem investigation, or Cause Map, click on “Download PDF” above. Click here to see our previous blog about intentional improper patient discharge, or “patient dumping”.

Equipment, procedural failure lead to resident scalding

By ThinkReliability Staff

While equipment and procedures were both in place to prevent resident scalding from too-hot baths, failures of both resulted in a resident receiving serious burns on August 13, 2013. The Health and Safety Executive (HSE) report was recently released on the incident, which resulted in prosecution for the care home and the employee responsible for the bath.

This incident illustrates the limitation in looking for the “one” root cause. There wasn’t just one thing that resulted in this incident; rather multiple failures were required to result in the tragic scalding. We can show these causes by performing a visual root cause analysis, known as a Cause Map. Note that the term “root cause” refers to a system of causes, much like the root of a plant is a system.

We begin the analysis by looking at the impact to the goals. Resident safety was impacted due to the very serious burning of a resident. The burning was so severe it resulted in the amputation of ten toes and the resident will never walk again. In addition, employee safety is impacted because of the emotional impact to the employee (known as the second victim). The employee safety is also impacted due to a risk of burns. The environmental goal is impacted due to the lack of temperature control and the compliance goal is impacted due to the prosecution of both the employee and the care home. Resident services are impacted from a resident being placed in a scalding bath. The failure of a thermostat is an impact to the property goal and the time required for response and investigation is an impact to the labor and time goal.

Beginning with one of the impacted goals (in this case we’ll begin with the resident safety goal) and asking “why” questions develops the cause-and-effect relationships that caused the incident. In this case, the resident’s injuries resulted from being placed in a scalding bath and being unable to exit due to physical and communication limitations. The resident was placed in the too-hot bath because the water in the bath was too hot, and the caregiver placed the resident in the bath. Both of these things (the water temperature being too high, and the caregiver placing the resident in the bath) had to occur in order for the injury to occur.

The water temperature was too high because of the failure of the immersion heater thermostat. The reason for the failure, as well as how long it was not working, is unknown. The caregiver placed the resident in the bath because she did not check the water temperature and failed to realize it was too hot. The caregiver appears to have been unaware of the thermostat failure, or certainly there would have been other safeguards in check. Additionally, there were inadequate thermometers provided to check the water temperature. (A manual check for comfort was still possible, though in this case could have resulted in a burn to the employee.) Although it was “required” to test the water temperature and record that the check had been done, there were no written instructions to that effect.

The care home has purchased portable thermometers for caregivers’ use, but the HSE also recommends the use of a secondary thermostatic cut-out, which would prevent boiling of the water tank even if the thermostat failed. The HSE has also provided a white paper “Managing the risks from hot water and surfaces in health and social care“, that discusses appropriate risk assessments and control measures to prevent burns of vulnerable care home residents.

To view the Cause Map of this incident, click “Download PDF” above.

Or, click here to read the HSE report of the incident.

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.


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.

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.

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.”


Smoke from wildfires in West may impact public health across the US

By ThinkReliability Staff

A significant portion of the United States is currently being affected by wildfires. The Valley and Butte fires in California, two of the worst in that state’s history, have killed five (all civilians found dead in their homes). The Tassajara Fire has resulted in another civilian fatality. The Rough Fire (also in California) has burned more than 141,000 acres. The US Wildfire Activity Public Information Map and National Wildlife Coordinating Group Incident Information System shows dozens more fires across the Western United States.

The wildfires are also impacting the population in areas not directly impacted by the fires. Public safety has been impacted by the deaths and risk for injury. Worker safety has been impacted as well; four firefighters were burned in the Valley fire. Even animal safety has been impacted; animals were left to fend for themselves in many areas that were evacuated rapidly due to changing conditions, leading to risk of injury or death. Tens of thousands of people have been evacuated. Hundreds of thousands of acres have been burned and thousands of buildings destroyed, causing a potential long-term impact on area businesses. More than 15,000 workers have been deployed to assist in fighting the fires.

The wildfires are also affecting air quality in areas not directly impacted by the fires. The smoke from these wildfires is causing environmental and health issues including asthma, chronic lung disease and even heart attacks. Janice Nolan, the assistant vice president for national policy at the American Lung Association says of recent air quality, “It’s really bad. I hadn’t seen ‘code maroon’ days, which is the most hazardous air quality, in years.” (The Air Quality Index reports the quality of outdoor air in color categories. Maroon, or “hazardous” represents a level of air pollution that means the entire population is likely to experience serious health effects. Lower categories indicate when members of more sensitive groups may experience health concerns.)

Health issues can occur when smoke is breathed in and enters the respiratory system. The organic particles that make up smoke can be so small they can bypass the body’s natural defenses (such as mucus and hair in the nose). The particles can even enter the bloodstream. This occurs any time a person is exposed to smoke. Says Sylvia Vanderspek, the chief air quality planner for the California Air Resources Board, “If you can smell smoke, then basically you’re breathing it.”

An average person can breathe in about 35 micrograms of particulate matter for only 24 hours before experiencing health problems. Unfortunately, the California air quality board has measured levels of particulate matter up to 34 micrograms in a day . . . and the fires have been burning for weeks and may continue for weeks more. Weather conditions impact not only the wildfires themselves but also where the smoke from those fires goes. Weather conditions this summer have meant that smoke issues have been seen into the Midwest.

The only really effective protection against health impacts from smoke is to stay inside with air conditioning on recirculate if in an affected area (based on the local air quality index). This has meant schools are holding indoor recess and sports practices and outdoor festivals have had to cancel performances. Idaho is considering establishing clean air shelters so the population can avoid breathing in smoke. Regrettably, most air masks won’t help, as they don’t protect against the tiny particles of concern. Instead, health officials reiterate that if the air quality in your area is poor, stay indoors to protect your health.

Filter to protect against blood clots implicated in deaths

By ThinkReliability Staff

An NBC investigation released September 3, 2015 raised concerns about the use of a specific retrievable inferior vena cava (IVC) filter, known as the Recovery. The issues behind the concerns are complex and some appear to impact more than one type of filter. A visual root cause analysis, known as a Cause Map, can clearly lay out all the causes associated with an issue, ensuring that all potential solutions can be considered.

The first step in a problem-solving process is to define the problem. Here the specific issue being investigated is the deaths and serious injuries associated with the failure of the Recovery filter. The Recovery was introduced in 2003 and was first implicated in a death in 2004. The Recovery aims to prevent blood clots from reaching the heart or lungs in patients who are unable to tolerate blood thinners and have been placed in a variety of healthcare facilities. An important difference between the expected and actual use of these filters is that studies have found that most are not removed in a timely manner.

The use of Recover filters has impacted the patient safety goal because at least 27 deaths have been related to its use. There are at least 117 lawsuits associated with these problems, impacting the compliance goal. Hundreds of additional non-fatal problems have also been reported, impacting the patient services goal. The operations goal is impacted by the filters not being removed. Lastly, the inadequate holding power of the arms of the filter (meant to hold it in place) can be considered an impact to the property goal.

The analysis begins with one of the impacted goals. Here, the primary concern is the impact to patient safety. The patient deaths result from the filter being pushed into a patient’s heart or lungs. This results from filter migration. In order for the filter to migrate, the force on the filter exceeds the holding power of the arms of the filter. Holding power can be reduced due to improper placement, filter fracture/ failure due to fatigue (a National Institutes of Health, or NIH, study found that 40% of filters fracture within 5.5 years) or design issues. Although these issues can impact any type of blood filter, the Recovery was found to have the lowest resistance to migration of filters examined. Force on the filter can be increased due to exertions, such as bowel movements or respiration, and/or large blood clots. Because these patients are known to have risk factors for blood clotting, this is a particular concern.

The time a filter is in place increases the risk of filter migration. The longer a filter is in place, the more likely it is to be impacted by the concerns discussed above. The use of these filters has been increasing. According to the US Food and Drug Administration (FDA), only 2,000 of these type of filters were installed in 1979; now about 250,000 are installed every year in the US. The devices used are approved by the FDA, though in the case of the Recovery, there are questions about the legitimacy of the review process; a “signer” on the application says her signature was forged. However, studies have found that evidence-based guidelines for implantation of these filters is not being followed, potentially leading to inappropriate use.
These filters (though designed to be temporary) are not being removed. A retrospective review of filter implantations published in the American College of Surgeons Surgery News found that only 1.6% of retrievable filters were removed during the 3-year study period. In 4.2% of cases each, filters were unable to be removed due to technical difficulties or thrombus within the filter. In most cases, though, it appears there was no attempt to remove the filter, believed to be due to a lack of physician oversight.

According to a FDA safety communication, physicians that implant a retrievable filter must remove it as soon as “feasible and clinically indicated”. This is true for all retrievable IVC filters, not just the Recovery. However, implanted Recovery filters are a particular concern – they are more prone to problems and haven’t been sold since 2005. If you believe you have an implanted filter, talk to your doctor about next steps.

To view a downloadable PDF with the causes of the filter issues, click on “Download PDF above. To learn more:

NBC Investigation

NIH Study

ACS Surgery Study

FDA Safety Communication

Saving lives by helping parents remember

By ThinkReliability Staff

Vaccination programs that increased the worldwide availability of vaccines have resulted in an estimated 7 million children surviving who would otherwise have died of preventable disease since the year 2000. Preventable diseases are those that can be prevented with a proper vaccination schedule.

However, about 1 in 5 children miss recommended vaccinations, leading to an estimated 1.5 million deaths that still happen every year from preventable diseases. Although the vaccines are getting to medical facilities across the world, children still need to be brought to the vaccines.   Parents may choose not to have their children vaccinated, typically due to a concern about the side effects (as occurred in the Disneyland measles outbreak, the subject of a previous blog.)   In some cases, parents just forget about the increasingly complex vaccination schedule.

People forget things; it’s a fact of life. But when parents forget about recommended vaccines, preventable disease and potentially death can be the result. Various solutions have been implemented across the world to make sure that all children receive all recommended vaccines. Potential solutions are evaluated on how easy they are to implement and how effective their planned result. Ideal solutions (“low-hanging fruit” or “slam dunks”) are solutions that are very effective and simple to implement.

The effectiveness and ease of implementation of solutions is dependent upon the circumstances. For example, calling parents to remind them of their child’s vaccine schedule is pretty effective – but it’s far easier to implement in a developed country than in a developing country. Thus the same solution – a phone call – appears in the “low hanging fruit” quadrant in developed countries, and in the “capital project” for developing countries. Click on “Download PDF” above to see how a solutions matrix may look for this issue.

Other solutions that have been implemented across the globe to help ensure children get all their recommended vaccines include:

– An anklet that fits around a newborn’s ankle with a punch-out reminder for each vaccine that costs only 10 cents each and has been tested in Peru & Ecuador (91% of 150 mothers surveyed said the bracelets helped them remember)

– Town criers in the villages of Burkina Faso made announcements about meningitis vaccines and community health workers went door-to-door answering questions about the vaccine (11 million people aged 1 to 29 were vaccinated within 10 days)

– PATH, a nonprofit that works on vaccines, provides poster templates advertising the importance of vaccines

– Rotary International had vaccine announcements added to the skirts of women in Kenya

– In India, an extensive polio vaccination program including transit and follow-up teams which led to the country being removed from the endemic polio list (see our previous blog)

All of these solutions have the potential to reduce deaths from preventable disease by increasing vaccination rates. In this case, as in many others, the most effective solutions need to be selected carefully. “Cultures, leaders and messaging are different in each country. So you have to study and use what’s most likely to work in order to build trust that the vaccine will be helpful,” says Amrita Gill-Bailey a team leader at Johns Hopkins Center for Communication Programs.

Attack on Hospital Staff Indicates Systematic Safety Issues

By ThinkReliability Staff

On July 13, 2015, a security counselor at a Minnesota psychiatric hospital was attacked and seriously injured by a patient. Even one injury to an employee is highly undesirable and should initiate a root cause analysis in order to reduce the risk of these types of events recurring. In the case of this hospital, this employee injury is one in a long line. In 2014, 101 staff injuries were reported at the hospital. From January to June of 2015, 68 staff injuries were reported. Clearly this is an extensive – and growing – problem at the site. According to Jennifer Munt, a spokeswoman for a union which represents 790 workers, “Workers at the security hospital feel like getting hurt has become part of the job description.”

An incident like this one can be captured within a Cause Map, or visual root cause analysis. The first step in the method is to define the problem in a problem outline. The problem outline captures the what, when and where of an incident, as well as the impact to the goals. Another important piece of information that is included is the frequency of similar events. Capturing the frequency helps provide the scope of the problem.

Understanding the details for one specific incident will likely reveal systematic issues that are impacting other similar incidents. That is definitely true in this case. Beginning with an impacted goal and asking “why” questions results in developing cause-and-effect relationships. Each cause that is determined to have contributed to an issue can lead to a possible solution. Each cause added to the Cause Map provides additional possible solutions, which, when implemented, can reduce the risk of future similar incidents.

In this case, we begin with the employee safety goal. An employee was seriously injured because of an assault by a patient at the hospital. The assault resulted from two causes, which were both required and so are joined with an “AND”. First, violent patients are housed at the facility. There were no other facilities available for the patient and the hospital is required to admit mentally ill county jail inmates because of a Minnesota law (known as the “48 hour rule” because of the time limit on admissions).

Second, clearly there was inadequate control of the patient. According to the union, limitations on the use of restraints, which are only allowed when a patient poses an “imminent risk”, mean that staff members feel that they cannot restrain patients until after they’ve been threatened – or assaulted. The union also says that inadequate staffing is leading to the increase in assaults. Specifically, union officials say at least 54 more staff members are required for the facility to be fully staffed.

The issues have caught the attention of state safety regulators and government. Multiple solutions have already been incorporated, including use of cameras, a separate admissions unit for new patients and protective equipment for staff. Additional staff is also being hired. The patient involved in the attack is isolated and under constant supervision. There’s no word yet on whether the use of mobile restraints, as requested by the union, will be allowed.

Says Jaime Tincher, Chief of Staff for Minnesota Governor Mark Dayton, “These are important first steps; however we will continue to assess what additional resources are needed to improve safety and treatment at this facility.” No less would be expected for ongoing issues that have such a significant impact on employee safety.