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!
Root Cause

Lack of Care After Overdose Led to Patient Death

by ThinkReliability Staff


An inquest into the death of a patient in a Milton Keynes hospital was completed on May 17, 2013 by the local coroner.  The coroner found that the staff failed to take and report appropriate observations and render effective treatment.  Diagramming the cause-and-effect relationships identified in the inquest in a visual root cause analysis, or Cause Map, allows identification of lessons learned and possible solutions to reduce the risk of this type of incident happening again.

We begin with the impacts to the goals.  In this case, the patient safety goal is impacted due to the patient death.   It was suggested that nursing shortages may have been related to the issues that occurred.  If this is the case, the shortages would impact employees.  The inquest that resulted due to the patient death can be considered an impact to the compliance and organization goals.  Last but not least, the insufficient patient treatment is an impact to the patient services goal.

Beginning with these impacted goals, we can ask Why questions to determine the cause-and-effect relationships that resulted in the patient death.  In this case, the patient death was due to respiratory arrest caused by an obstructed airway.  The patient being placed on her back while unconscious (though sources differ on whether the patient was placed on her back or her side) due to a drug overdose.   The patient overdose was due to a self-administered overdose and not being administered the antidote for the drugs on which she had overdosed.

The patient was not given an antidote for the drugs on which she overdosed.  The family of the patient, who had a history of mental illness and frequented the hospital, believes that the staff believed she was faking her symptoms.

Through the patient’s eleven hours within the hospital’s Accident & Emergency (A&E) Department, only 2 formal observations were recorded.  One set of observations was recorded on a glove, which was later lost.  Abnormal results from these observations were not passed along from the healthcare aid who was responsible for the patient, likely due to nursing shortages.

Once all of the causes related to the incident have been recorded within the Cause Map, solutions can be brainstormed and recommended for implementation.  The coroner involved in the case has requested the Secretary of State for Health implement changes that would require seriously ill patients to be observed by nurses rather than healthcare assistants. The hospital has stated that they “have conducted an investigation to ensure lessons are learned” and “will be continuing to improve our service in regard to emergency patients”.  The hospital has commissioned training for their healthcare assistances to improve their skills.

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

Root Cause

11 Patients Killed in Nursing Home Fire

by ThinkReliability Staff

A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia.  At least 11 residents died as a direct result of the fire and nearly 100 were evacuated.    A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)

The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson.   The reasons for the arson are unclear and may never be fully understood.  However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.

We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy.  We begin the analysis with the “What, When and Where” of the event, captured in a problem outline.  Additionally, we capture the impacts to an organization’s goals.   In this case, the patient safety goal was impacted due to the deaths.  There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder.  Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million.  (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.)  Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.

Capturing the  frequency of similar issues can help provide perspective on  the magnitude of nation and world-wide issues.  I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year.  There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.

Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts.  In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility.  The fire initiation, as discussed above, is believed to be due to arson.  However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.

Studies after the event showed how critical sprinklers can be to slow the spread of a fire.  On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016.  It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.

To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.

Root Cause

Successful Emergency Response to Boston Bombing

By ThinkReliability Staff

The successful activation of emergency plans allowed 8 hospitals in the Boston area to treat 144 trauma patients injured in the bombings that occurred April 15, 2013 near the finish line of the Boston Marathon.  Even with that heavy burden, these hospitals ensured the continued safety of patients and staff during a very unsure time, as well as assisting the police and Federal Bureau of Investigation (FBI) with the ongoing investigation.

While details on the bombings themselves are still being determined and disseminated, it’s apparent that emergency planning and preparedness processes within the area Boston hospitals were successful in allowing an ‘unprecedented’ response.  We can view the response to the bombings by the area hospitals in what we like to call a root cause “success” analysis.  After all, lessons can be learned not only from what didn’t go well, but also what did.  Hospitals around the country can learn from the response by the Boston area hospitals to this trauma.

When Massachusetts General asked hospital staff from Israel, who unfortunately see this kind of trauma on a far more regular basis, to give emergency response training they likely did not suspect their hospital to be the site of a horrific mass trauma like that experienced in Boston.  The hospital’s experience with war-style trauma was certainly extremely helpful in dealing with the aftermath of this kind of trauma, rarely seen outside of war zones.  As Dr. Ron Walls, the chairman of the Department of Emergency Medicine at Brigham and Women’s Hospital stated, “For many, many people in emergency medicine who are practicing domestically and not in the military, these are once-in-a-lifetime events.”

For once-in-a-lifetime events, facilities have to hope that the training and education they’ve provided to their staff, and the processes that they’ve developed for dealing with emergencies, can stand up to the tragedy.  In this case, these Boston hospitals (once they have time to take a breath, which may not be for a while), should give themselves a pat on the back for their amazing handling of a tragic event.  Hospitals elsewhere should take note and ensure that their emergency procedures will allow the same sort of successful response.

A pat on the back should also go out to the staff in the medical tent at the finish line, whose quick actions and extensive equipment allowed on-scene stabilization and quick transfer of the severely injured to the area hospitals.  Lastly, the many spectators who kept their cool and assisted on scene should also be commended.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to learn more about the emergency procedures at Massachusetts General.

Root Cause

Reuse of Insulin Pens May Have Spread Hepatitis

By ThinkReliability Staff

After a similar incident at a Veterans hospital, a hospital in New York reviewed its insulin injection procedures and discovered that insulin pens may have been used for more than one patient.  Re-use of insulin pens for more than a single patient carries a small risk of cross-contamination, which can result in a patient being infected with a communicable disease, such as hepatitis B, hepatitis C, or HIV.

The hospital notified 1,915 patients who had received injections between November  2009 and January 2013 of the possibility for contamination and recommended testing.  Twelve patients have tested positive for Hepatitis C, and one has tested positive for Hepatitis B, though an investigation is ongoing to determine if this is related to the injections.

The use of insulin pens resulted in 30 outbreaks from syringe or needle reuse over ten years, from 2001-2010. So, although the possibility for cross-contamination is considered low, the risk for the spreading of communicable diseases is unacceptably high.

The potential for spreading communicable diseases is an important impact to the patient safety and environmental goals.  We can examine these impacted goals and the cause-and-effect relationships that led to these impacts, in a Cause Map, or visual root cause analysis.

We begin by defining the impacts to the goals.  In addition to the patient safety goal, the compliance goal is impacted because re-using insulin pens is against recommendations by the FDA and CDC.  The organizational goal is  impacted due to a lawsuit from the patients who have tested positive for Hepatitis B and Hepatitis C.  Patient services are impacted due to the improper reuse of the insulin pens, and the labor and property goals are impacted by the additional follow-up, testing and potential treatment for the almost 2,000 patients affected.  Once we have determined the impacts to an organization’s goals, we can ask “Why” questions, which helps develop cause-and-effect relationships that resulted in these impacts.

Insulin pens are designed for multiple injections, meaning that there is stored insulin within the cartridge after a single injection is given.  Backflow of blood into the pen can result in the remaining insulin being contaminated.  This can result in the spread of communicable disease if the pen is then used on a different patient for subsequent injections.

Because it is known that insulin pens should not be used on multiple patients, it is evident that there was an issue with the procedure or policy regarding use of insulin pens.  It is unclear what the specific issues were relating to this incident, but the hospital involved has reviewed and reinforced policies and procedures related to insulin injection.

Many facilities, including the hospital discussed here, which discovered the potential for re-use during a review after a similar incident at a Veteran’s hospital, have discontinued the use of insulin pens due to the potential for cross-contamination.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read the hospital’s press release.

Click here to visit our previous blog about about hepatitis B and C.

Click here to visit our previous blog about a different contamination issue involving hepatitis C.

 

Root Cause

Rabies From Donated Kidney Kills Recipient

By ThinkReliability Staff

A kidney donation recipient died in February, 2013.  It was determined that his death was due to rabies – specifically rabies that had been transferred with the donated kidney during the transplant in September 2011.  Although infectious disease transmission through transplant – especially rabies – is rare, there is benefit in visually diagramming a root cause analysis of this event in a Cause Map.   A Cause Map begins with the specific impacts to an organization’s goals resulting from an incident, and shows the cause-and-effect relationships that led to those impacts.

In this case, the patient safety goal was impacted due to the recipient death.  The receipt of organs infected with a disease such as rabies is an impact to the patient services goal.  Three other recipients also received organs from the same donor but have not shown symptoms of rabies.    Their treatment is an impact to the property and labor goals, due to the cost, time and inconvenience of those treatments.

The impacted goals form the first cause-and-effect relationship in our Cause Map.  We ask “Why” questions to determine other cause-and-effect relationships.  In this case, the donor death was due to rabies.  The donor was infected with rabies from an infected transplanted organ, and was not treated for rabies.  The recipient was not treated for rabies as the symptoms did not emerge until a year after the transplant (rabies can have a long incubation period).  The donor organs were infected with rabies from an unknown cause, though rabies usually results from contact with wild animals (specifically, this strain of rabies appears to be from a raccoon).   The transplant medical team was unaware that the donor had rabies.

Though the donor had encephalitis, it was thought that it was due to a food-borne illness.  (Detail on how the diagnosis was obtained has not been released.)  While there is testing for certain diseases performed on donor organs, due to the time constraints on the viability of the organ, testing for rabies is not generally performed.  However, new guidance from the Disease Transmission Advisory Committee (put out after this donation occurred) urges caution in use of organs from donors with encephalitis, perhaps including more robust testing for specific illnesses, or using only certain organs.

Due to an acute shortage of viable donated organs, some believe that organs from disease-positive donors should be used, and treatment started immediately.  With many in need of transplants dying on the waiting list, this may be a more practical approach, though there are certainly concerns about transmitting diseased organs to those who are already very ill, and who will be taking immune suppressing drugs to prevent rejection of transplanted organs, making them more susceptible to such diseases.

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

Read our previous blog about a recipient who died of lung cancer after receiving the lungs of a heavy smoker

Root Cause

Helping the Blind See

By ThinkReliability Staff

Retinitis pigmentosa is an eye disease which results in the degeneration of photoreceptor cells in the retina.  Although it is uncommon, it is estimated that 100,000 Americans suffer from it, but a new device may be able to help them.

In normal sight, the light from a signal enters the eye and contacts photoreceptor cells in the retina.  The photoreceptor cells generate electrical impulses, which are sent to the brain by the optic nerve, allowing the vision to be interpreted by the brain.  In retinitis pigmentosa, their photoreceptor cells deteriorate, short-circuiting the vision process, eventually to the point where there is no vision at all.

To assist in our understanding of the normal vision process, and the problems with it resulting from retinitis pigmentosa, we can use a process map, or a visual step by step diagramming of any process that is examined as part of a root cause analysis.  Although in this case the process is a biological one, diagramming any process that is not producing the desired results can provide important information to develop solutions that allow the process to  again provide the desired results.

With advanced retinitis pigmentosa, all vision can be lost.   Although researchers continue to attempt to discover ways to restore as much vision as possible, any improvement can improve quality of life.  A device called the Argus II, which was approved by the FDA for use in the US on February 14, 2013, aims to help those with retinitis pigmentosa – and possibly in the future those who are blind from macular degeneration.  The device was approved in Europe in 2011 for any type of outer retinal degeneration.

The device uses a camera, video process and electrodes which do the processing work normally performed by photoreceptor cells and the optic nerve.  The electrode provides a pixelized light/dark pattern to the brain, which can allow sufferers to  see outlines and differentiate between light and dark.  Again, a process map can help demonstrate how the device works to bypass the normal vision process.

To view a process map of normal vision, and partial vision provided by the Argus II device, please click “Download PDF” above.  Or click here to read more.

Root Cause

Hiding in Plain Sight

By ThinkReliability Staff

Before you read the rest of this blog, click here and take a look at the radiograph. Did you notice anything  . . . odd?  If not, you’re in good company.  The image shown was used in a study with trained radiologists.  A vast majority – 83% – did not notice the gorilla in the upper right hand corner of the lung.

Yep, that’s right.  There’s a gorilla in that scan.  Did you miss it too?

This study was based off a study performed in 1999 that drew attention to the “inattentional blindness” effect.  Essentially, it means if you’re busy doing something that requires a lot of concentration, there’s a lot you can miss.  This new study attempted to determine whether people who were “trained for looking” – i.e. radiologists – would be better at noticing something “off”.  Actually, they were worse, based on the percent of people who missed the gorilla in the original study – 50% – being far less than the percent of radiologists – 83% – that missed the gorilla in the radiograph.  What’s particularly disturbing is that what the radiologists were looking at was a radiograph, something they’ve been specifically trained to evaluate.  To be fair, they were specifically asked to look for cancerous nodules . . . not large, hairy animals.

What are the broader implications of this study?  Well, the first is acknowledgement of the possibility of missing the seemingly obvious.  This is not, of course, limited to radiologists.  Examples of this happening are seen all over healthcare – when alarms are assumed to be malfunctioning, rather than actually indicating an issue that needs to be dealt with.  Or when sponges are left inside a patient.  It’s certainly not because the surgical staff isn’t concentrating.  Or when you have a patient seemingly ready for surgery . . . only it’s not for him.  When you have a patient who’s ready to go, and a staff who’s ready to go, it is only to easy to assume that – because everything LOOKS right, it is.

The next question, of course, is what can be done to deal with “inattentional blindness”, now that we know it exists for anyone, regardless of specialized training?  Strategies that have been developed to deal with all kinds of medical errors can also help with inattentional blindness.  Taking time to catch your breath, then going back to look again – such as occurs when using a time-out prior to surgery – can give you a fresh look that is more likely to catch those gorillas.  It can also help to use more sets of eyes, by bringing in different staff members from different areas of expertise.  Checklists can also help to focus on the obvious – forcing a check on a patient’s identity, for example.

Much like in the gorilla studies – where people overestimated their ability to notice outlying events – medical personnel who have effectively incorporated time-outs and/or checklists have been surprised at the number of potential events that have been caught by these aids.  Obviously, they’re not a panacea, or a replacement for a well-trained, caring staff.  So, the next time something seems “off”, take another look.  Maybe it’s a gorilla.

Root Cause

Delay in Standard Sepsis Protocol May Have Cost Patient Her Life

By ThinkReliability Staff

Information found in this blog is based on an article from Health Affairs, where an emergency physician describes his mother’s fight against neutropenic sepsis contracted after her second bout against cancer.

In this case, the sepsis killed the patient, impacting the patient safety goal.  Additionally, the delay in treatment – even if it did not result in the patient’s death – is an impact to the patient services goal.   With delayed patient services, there is the potential for a lawsuit, or other potential action against the hospital.  We’ll consider this an impact to both the compliance and organizational goal.  We can visually diagram the causes that led to these impacted goals in a Cause Map, or visual root cause analysis.

Here, the patient death was due to her inability to fight neutropenic sepsis, which resulted from a systemic infection that the body – having depleted infection-fighting cells during recent chemotherapy – was unable to fight off.  Medical intervention can improve the survival rate, especially when life-saving measures are begun quickly and followed completely.  In this case, the patient was hospitalized for 23 hours before sepsis protocol was begun.

The patient’s primary doctor was her oncologist, who did not consult with an intensive care doctor.  Despite recommendations to have care of new ICU patients fall within the responsibility of an intensive-care doctor, this solution was not implemented at this particular hospital due to “political barriers”.  It can thus be surmised that this may have been a cause to the delay in consultation during the case as well.

The sepsis protocol was begun only when care was transferred to the intensive-care doctor as a result of the patient’s son requesting transfer to a different hospital.  Perhaps the staff was unaware of the seriousness of the situation, as the monitoring of the patient appeared inadequate.  The transfer of the patient to the ICU was also only done at the specific request of the patient’s son.  Based on the description of the experience at the hospital, it’s not clear why the patient’s doctor did not order the standard sepsis protocol.

The hospital involved in the case has updated its guidelines in treating sepsis.  Hopefully this will successfully result in the reduction of cases such as this one.

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

Root Cause

ER Visits Due to Consumption of Energy Drinks More Than Doubled

By ThinkReliability Staff

Consuming high levels of caffeine can lead to various health concerns that may require emergency medical attention.  According to the Substance Abuse & Mental Health Services Administration: “Consumption of energy drinks is a rising public health problem because medical and behavioral consequences can result from excessive caffeine intake.”  Energy drinks can contain extremely high levels of caffeine, which are not required to be listed on the  label.  Emergency room visits due to consumption of high-caffeine level energy drinks more than doubled from 2007 to 2011.

The issues associated with consumption of energy drinks can be documented in a Cause Map, or visual root cause analysis.  We begin with the impacts to the goals; the safety goal is impacted due to the health risks.  Additionally, increased ER visits and media attention to the issue can be considered impacts to various organizations’ goals.

Beginning with the impacts to the goals, asking “Why” questions allows us to uncover the cause-and-effect relationships that lead to these concerns.  Consuming high levels of caffeine can lead to health concerns, including dehydration, headaches, and even seizures.  Most energy drinks contain high levels of caffeine – equivalent to the caffeine in several cups of coffee – but are not required to list the amount of caffeine on the label.  Because some of these beverages are marketed extolling positive health effects, consumers may be unaware of potential risks.  Because some energy drinks are sometimes considered beverages  and sometimes are considered dietary supplements, regulation is limited.

More attention is being called to this issue, along with calls for more regulation and requiring disclosure of the amounts of  caffeine in energy drinks in the hopes that with more information, both to consumers and healthcare professionals, will result in fewer emergency health concerns.

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

Root Cause

Transplant Recipient Dies of Lung Cancer After Receiving Smoker’s Lungs

By ThinkReliability Staff

After 18 months on the transplant list, a patient in England finally received a new set of badly needed lungs.  However, though required by NHS Blood and Transplant since March 2011, the medical history of the donor – specifically that the donor was a heavy smoker – was not disclosed to the recipient, who died shortly after of lung cancer.

The issues causing this death can be examined in a Cause Map, or visual root cause analysis.  We begin an investigation by determining which goals were impacted by the event.  In this case, the patient safety goal was impacted due to the death of the transplant recipient.  Additionally, patient services were impacted because the patient was given “higher risk” organs.  Lastly, the worldwide shortage of organs can be considered an impact to the property goal.  Once we have determined these impacts to the goals, we can ask “Why” questions to develop the cause-and-effect relationship leading to the issue.

The patient death was due to lung cancer.  The patient suffered from lung cancer because she received a lung transplant using lungs from a smoker.  The patient was unaware of the donor history though disclosure of the medical history of a donor is required.  Additionally, more patients are being given what are known as “higher risk” organs.  This includes organs from smokers, the elderly, and even drug users.  39% of lung transplants are from smokers.  Doctors believe that patients are better off with these organs than waiting on the transplant list.  Only a handful of transplant recipients have died from diseases related to their donors’ health, but every year about1,000 people in the UK die waiting for a transplant.  The quality of available organs is decreasing due to longer lifespan and obesity.  Additionally, the number of organs has always been less than needed.  The number of potential organ donors is small, due to a combination of factors, including personal reasons for not donating and families not donating a loved one’s organs when their wishes are not made clear.

Disclosure of a donor’s medical history is already required.  Increasing the number of donors is desperately needed to ensure adequate availability of organs.  You can contribute by becoming an organ donor and making your wishes clear to your family.  The medical profession is attempting to increase the usability of organs, using methods such as the one discussed in a previous blog.

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