Category Archives: Never Event

Another Bubble You Don’t Want to Be Part Of (Air Embolisms)

By ThinkReliability Staff

Air embolism (an air bubble trapped in the blood vessels) in hospital patients is one of the “never” events that will no longer be reimbursed by Medicare. It can also cause patient death, stroke, heart attack, or other serious complications. Thus it is in the best interest of medical care facilities to reduce the occurrence of air embolisms. In order to do this, first we must determine the causes of air embolisms. We will do this as a root cause analysis example.

Many people think of root cause analysis as a tool to determine what WENT wrong, but it can also be used to determine what COULD go wrong. We will look at the issue of air embolisms in a Cause Map to determine the causes, and then the solutions that can be implemented to reduce the occurrence of air embolisms.

For step 1, we outline the problem. The problem here is air embolisms. They affect the vascular system and often occur during surgery or as a result of using a catheter. Air embolisms impact the patient safety goal because they can cause tissue damage, serious injury, or even death. It impacts the compliance goal because it is a “never” event, and impacts the materials and labors goal because (according to Medicare data) it results in an average hospital bill of over $71,000 (which may not be reimbursed). There are approximately 57 cases/year (Medicare data), resulting in an annual cost of over $4 million.

Step 2 is the analysis. We begin with the impacted goals (we’ll look at the patient safety and compliance goals here). These goals are impacted by an air embolism. For an air embolism to occur (i.e. for air to get trapped in a blood vessel), the vasculature must be exposed to air AND the pressure gradient must favor air entering the blood vessels (normally it would be the other way around – if a blood vessel is opened, blood will come out rather than air going in). The pressure gradient could favor air entering blood vessels if surgery above the heart is performed upright or due to low central venous pressure. This could be caused by decreased blood volume or deep inspiration, such as coughing or laughing (there are case studies of post-surgical patients keeling over after a good joke).

There are several ways the vasculature can be exposed to air. Removing a catheter or performing surgery may expose blood vessels to the atmosphere. Additionally, air can enter the blood vessels through a catheter. This can occur if the catheter is damaged or opened, or if air is forced into the catheter.

Even more detail can be added to this Cause Map as the analysis continues. As with any root cause analysis investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.

Once the Cause Map has been completed to desired detail, we can look for solutions. Any cause on the Cause Map can have a solution (or more than one), but not all causes will. Here we’ve identified some of the best practices towards preventing air embolisms.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

Return to Root Cause Analysis Healthcare Home Page

You left WHAT in there? (Foreign Objects Retained After Surgery)

By ThinkReliability Staff

Leaving a surgery sponge (gossypiboma) or other foreign object in a patient’s body can cause serious complications or even death. According to Medicare data, there were 750 such cases in 2007, which cost an average of $63,631 per hospital stay. That’s more than $47 million a year, and does not include potential legal costs associated with such events.

We can examine the problem of post-surgery foreign object retention by putting it into a visual root cause analysis (or Cause Map). A foreign body may be left inside a patient if it is not visible in their body, is not detected by radiography, and is not recognized as missing. We continue to ask why questions to fill out our root cause analysis.

Why would the object not be detected by radiography? The object may not be detectable by radiography, as some sponges are not. The object might not be noticed in the radiography, if the person reading it is not adequately trained, or if there is no double-check. Or, radiography might not have been used. This is contrary to some organization’s recommended procedures.

How would the object not be recognized as missing? The instrument/sponge count may be inaccurate, or it may not have been done at all, which is also contrary to recommended procedure.

Since we have “Did not follow procedure”, we need to outline what the proper procedure should be. We call this a “Process Map”. Here we show the procedure for instrument and sponge removal verification. Instruments and sponges are counted before, and twice after surgery. If the count does not match, there is a physical re-examination, and radiograph to determine whether the object has been left inside the patient. Different organizations may use a slightly different process, but what is important is that it is formalized and examined in the case of any incidents, such as a left-behind sponge or instrument.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map made with our root cause analysis template.

Return to Root Cause Analysis Healthcare Home Page