Category Archives: Root Cause Analysis

Root Cause Analysis

Deadly medication error illustrates danger of discharge period

By ThinkReliability Staff

Medical errors can happen anywhere and at any time. However, these errors may be most likely to occur at transitions, especially the transition from the hospital to home when follow-up care is still required. Says Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine, “Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs. The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

The case of a woman’s death from medication errors during that transition period illustrates multiple errors that can occur during this period. We will capture the known details of this issue in a Cause Map, or root cause analysis. The first step in the Cause Mapping process is to capture the what, when, where and impacted goals in a Problem Outline. In this case, the patient passed away October 30, 2013, after discharge from a regional medical center in Missouri, where the patient was treated for congestive heart failure. Organizational goals that were impacted by the patient death (an impact to the patient safety goal), settlements with both the hospital and pharmacy (impacts to both organization’s legal/ financial goals), and the patient being administered a high dose of the wrong medication (an impact to the patient safety goal).

These impacts to the goals become “effects” of cause-and-effect relationships. The Cause Map contains all the cause-and-effect relationships that led to these impacted goals. Causes included in the map are verified with evidence, which can be provided by a variety of sources. Causes can be determined by asking “Why” questions, but more than one cause may be required to produce an effect. In this case, all necessary causes are included and joined with an “AND”.

The patient safety goal was impacted because of a patient’s death due to multiple organ failure when her bone marrow became unable to create blood cells as a result of an overdose of methotrexate. Methotrexate can damage blood cell counts and is primarily used to treat cancer and severe arthritis. The patient was administered a high dose (for methotrexate) of a drug that was not prescribed for her. When the patient left the hospital, the hospital phoned an order for a daily dose of the diuretic metolazone. However, according to court evidence, the order was written down by a pharmacy technician as a daily dose of methotrexate.

Because of the side effects of methotrexate, it is included in a list of eight “high-alert” medications that warrant special safeguards to prevent incorrect dispensing. The typical dose of methotrexate is much lower, usually only once or twice a week. Despite this, the pharmacist missed the error. In a testimony, he was unable to identify a specific reason for this oversight. The pharmacy manager said “there was a breakdown in the system.”

There were more opportunities for this error to be caught before this drug was dispensed to the patient. The patient herself could have noticed the incorrect medication based on the name or information on the enclosed information sheet. However, the patient likely did not fully understand the discharge instructions. Federal data shows that less than half of patients say they’re confident they understand discharge instructions. This patient was also receiving home health care, but neither of the two nurses that saw the patient identified the medication mix-up. Even though a primary purpose of home health care is to develop and follow-up on patient care, a 2013 government report found that more than a third of facilities did not do this properly. Medicare requires that home health agencies verify patient’s medications and check for possible interaction, but inspectors found that nearly a quarter of home health agencies inadequately reviewed or tracked medications for new patients. One of the challenges is that the typical providers of post-discharge patient care (nursing homes, rehabilitation facilities and home health care providers) did not receive any of the funding provided by Congress to upgrade to electronic medical records.

Several systemic issues were identified in this case and actions meant to improve these issues are still ongoing. One reason for increased use of electronic medical records is to avoid delivering prescriptions over the phone, which can result in transcription errors. Ensuring patients better understand their discharge instructions is another goal that could improve patient safety. Lastly, improvements to home health care agencies to ensure their required tasks are being completed effectively is clearly needed, but it has been difficult to determine the most effective way to do this.

To view the Cause Map of this incident, click on “Download PDF” above. Or, click here to read more.

Root Cause Analysis

NIH suspends work at two facilities

By Kim Smiley

Research has been suspended at two National Institutes of Health (NIH) facilities – a National Cancer Institute laboratory working on cell therapy production and a National Institute of Mental Health facility that makes positron emission tomography materials – over concerns about patient safety. A panel of experts determined that these facilities were not in compliance with quality and safety standards and they are shut down pending a review and any necessary upgrades.

A Cause Map, a visual format for root cause analysis, can be built to help understand this issue.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information for an issue, along with how the issues impacts the overall goals. Thankfully, no patient harm has been identified as a result of issues at the facilities, but the potential for patient harm existed and potential impacts should be included on the Outline. No new patients will be enrolled in the affected trials until the issues are resolved and this is an impact to the schedule/operations goal. Once the Outline is complete, the Cause Map is then built by asking “why” questions and the answers are laid out to visually show the cause-and-effect relationships. (Click on “Download PDF” to see a completed Outline and high level Cause Map of this issue.)

So why was work at two NIH facilities shut down? A little background is needed to understand this issue. In April 2015, fungal contamination was found in products that were supposed to be sterile that were prepared at a different NIH facility, the Clinical Center’s Pharmaceutical Development Service. The investigation into the contaminated product found multiple deficiencies, both in the facility itself and in work practices. The deficiencies included a filter missing in an air handling system and insects found in two light bays in clean rooms. (Read our previous blog to learn more.) Following this issue, the director of NIH appointed a panel of experts to review safety compliance at all other NIH facilities that produce sterile or infused products for administration to research participants.

The panel’s evaluation is still underway, but preliminary findings determined that the two facilities in question are not in compliance with quality and safety standards and production has been suspended as a result.  The panel found that NIH has many outdated or inadequate facilities and that personnel lack expertise on applicable regulations, but no specific details about the deficiencies found have been released. NIH plans to do a rigorous review to identify and correct issues found before these facilities resume manufacturing sterile products. No timeline has been given at this point.

The final step in the Cause Mapping process is to identify and implement solutions to reduce the risk of similar errors reoccurring in the future. In addition to correcting the deficiencies found at these facilities, NIH is working on creating more oversight to help ensure manufacturing facilities are in compliance with safety regulations. The panel recommended the creation of both an outside hospital board to oversee the clinical center and a new central office to coordinate research quality and safety oversight.

Only time will tell how effective these solutions prove to be, but I find it promising that NIH proactively reviewed all of the facilities that produce sterile or infused products for administration to research participants following the fungal contamination issues last year.  It may be painful and embarrassing to suspend work at facilities, but the process is at least moving in the right direction if problems can be corrected before patients are harmed.

Root Cause Analysis

Family of Sepsis Victim Fights for Better Care

By ThinkReliability Staff

New York state has become a leader in identifying and treating sepsis. But it wasn’t always this way. On April 1, 2012, a twelve-year-old boy named Rory Staunton died from sepsis in a New York hospital (the subject of a previous blog). There were multiple opportunities that could have more quickly identified his sepsis, and potentially saved his life. After his death, Rory’s family founded the Rory Staunton Foundation For Sepsis Prevention. Part of the foundation’s mission is to improve diagnosis and treatment protocols for sepsis.

The foundation landed a success when New York state adopted what are known as “Rory’s Regulations” on December 31, 2013. These regulations require “health care providers to develop and implement protocols to rapidly diagnose and treat sepsis infections”. In addition, the state adopted hospital pediatric care regulations which specifically addressed many of the causes identified in Rory’s case. These include requirements to:

– Review of test results by a clinician familiar with the patient’s case: Blood tests ordered to be run immediately were not reviewed by the doctor who ordered them. Although initial tests showed abnormalities within an hour of Rory’s arrival, these results were not provided to the emergency department at all.

– Provide test results to the primary care provider: The test results were not provided to Rory’s primary care provider.

– Improve communications of test results to patients and parents: The test results were not provided to Rory’s parents

– Keeping patients in the hospital while awaiting critical test results: Rory had already left the hospital when the test results arrived. Because the results of the test were a matter of life or death, had his discharge been delayed while awaiting the results, the outcome may have been different.

Even with ensuring that test results make it into the right hands, diagnosing and treating sepsis is difficult. Rory’s Regulations also require developing protocols that will assist in sepsis detection and treatment. An international task force released updated definitions of sepsis and septic shock, as well as clinical guidance, in February 2016. The Centers for Medicare and Medicaid launched a new core measure for fiscal year 2016.

Another mission of the foundation is to increase public awareness and understanding of sepsis. The foundation requested the Centers for Disease Control and Prevention help them in this mission. The CDC launched its new sepsis website on May 29, 2014.

While New York’s regulations seem to have been a success (the state’s Department of Health estimates they will save at least 5,000 lives each year), the foundation isn’t stopping there. Their stated goal is to have similar regulations in place across the US by 2020.

To view the cause-and-effect relationships and the associated solutions laid out visually in a Cause Map, please click on “Download PDF” above. Click here to learn more about the Rory Staunton Foundation For Sepsis Prevention.

Root Cause Analysis

Questionable medical advice leads to death of old lady who swallowed a fly

By ThinkReliability Staff

There was an old lady who swallowed a fly. This was presumably accidental, but whatever the reason, it happens. Then the old lady swallowed a spider. Again, it happens. And, if you were looking for a Darwin-ish way to catch live flies, this seems to make sense. However, at that point, whether due to increasing hysteria or bad medical advice (possibly from the internet?), the old lady then proceeded to swallow progressively larger and larger animals until it led to her untimely death.

After swallowing the spider which, according to an eyewitness, wiggled and jiggled and tickled inside her, the old woman apparently felt that ingesting another animal that could catch the spider would be a good idea. So, she swallowed a bird. Now, this isn’t entirely illogical – birds do catch spiders. But the idea of ingesting a bird whole would give most of us pause. Even if it didn’t, there aren’t many types of birds that many people could easily swallow whole. Regardless, this is what the old lady did.

Continuing to move up the food chain, the logical choice of animal to catch a bird is a cat. Of course, many of us have cats as pets, and can’t imagine swallowing them, even for the purposes of catching a bird. But again, this is what the old lady did. Maybe the horror of what she had done finally got to her, because her next actions didn’t seem to answer to logic. Next, the old woman swallowed a dog. Although dogs chase cats, it’s unclear how often they “catch” them. A better choice to “catch” a cat would have probably been a cardboard box.

Then the old lady went for a goat. While goats are good for eating grass (and various other things), there’s no real evidence that goats have any desire to catch dogs. In fact, dogs are occasionally used for herding goats, so it’s unclear why the old lady would have turned to a goat next. But again, that’s what she did.

By then the delirium was apparently at an all-time high, because the old lady then swallowed a cow. It has been verified by veterinary experts that cows are not capable of catching ANYTHING, much less a goat (plus the dog and cat that are likely still running loose in there). After swallowing a cow, the old lady then gave one last ditch effort to finally wrangle all those animals she had swallowed and swallowed a horse. Beyond the obvious physical challenges involved in swallowing a horse (clearly involving an unhinged jaw and a very, very flexible throat), there are, again, moral considerations as well. But a horse does seem a better choice to wrangle a bunch of animals, although horses used for herding are generally controlled by a human rider . . from the outside. Sadly, eating a horse was too much, even for our very sturdy old lady, and that was the last thing she ever swallowed.

While the desire to catch animals already swallowed appears to be the main driving force behind the rather interesting last meal of the old lady, the question “why” is always close at hand. In particular, why did the old lady choose this particular line-up of animals? Because our best witness (the old lady) is speaking no more, we can only guess at what led to her decisions. I suspect that she came upon a nursery rhyme on the internet and confused it for advice. Which is why, any time you have a concern about something that somebody swallowed, it’s best to see or call a doctor, or poison control. (And if you swallow a fly, your stomach acid will make quick work of it, so no worries.)

Because of the risk of death involved, I propose that we place warning signs on all animals not meant to be consumed whole. The obstacles in implementing this solution are many, but when deaths of old ladies are at stake, one cannot be too safe.

To view the investigation of the old lady’s death, please click “Download PDF” above. Happy April Fools’ Day from ThinkReliability!

 

Root Cause Analysis

Do you know how an MRI works?

By Kim Smiley

About 30 million magnetic resonance imaging (MRI) scans are performed in the United States each year. They are most frequently used to create images of the brain and spinal cord, but can also help diagnose aneurysms, eye and inner ear disorders, strokes, tumors and other medical issues. MRIs are painless and do not expose a patient to potentially harmful radiation, making them one of the safest medical procedures available.

MRIs are fairly common and most people have heard of them, but do you have any idea how they work?  A Process Map is used to document how a work process is performed, which can be useful when explaining how a process works to somebody who is unfamiliar with it.  To view a high level Process Map of how an MRI is used to create an image, click on “Download PDF”.

The high level Process Map is very basic and would not be useful to somebody trying to learn how to perform an MRI, but it might be helpful in explaining to a patient what to expect during the procedure and how an MRI image is produced.  A more detailed Process Map that included information on each step that needs to be done to perform an MRI could be built for use as a training aid or as a way to document best work practices, but sometimes a basic high level Process Map can also be helpful.

So how does an MRI create detailed images of the inside of a human body? An MRI uses a strong magnet to create a large, steady magnetic field around the patient’s body.  Many atoms, such as hydrogen atoms, have strong magnetic moments that cause them to align in the same direction when exposed to a magnetic field.  Once atoms in the patient’s body are aligned along the field lines of the large magnet, the MRI machine produces a pulse of radio frequency current.  During the pulse of energy (which is extremely brief), atoms in the patient’s body absorb this energy and rotate to align with the radio frequency current.  Once the pulse is over, the atoms will rotate back to their original position, emitting energy.  Atoms in different types of body tissue return to their original positions at different rates and release different energy signals. The body is pulsed many times by different frequencies at different locations to target the specific type of issue being looked at by the MRI. All of the energy emitted by the atoms during these pulses is collected by antennas and a computer uses a mathematical formula to convert the data into images.

Obviously this is a very high level explanation that leaves out a lot of detail, but the basic idea is that an MRI uses changing magnetic fields and the body’s natural magnetic properties to produce detailed images of the human body.  The patient’s role during an MRI is simple (if maybe a little claustrophobic), but the process by which the MRI image is produced is fairly complicated to understand.  Having a simple, visible explanation of what is going on may help make a patient feel more comfortable with their experience.

Can you think of a time when it would be useful to explain the big picture of a work process to somebody, whether a manager or a customer? Creating a simple high Level Process Map to help explain a process to people that aren’t directly involved in the work is something that can be useful across many industries.

Root Cause Analysis

Study finds many patients don’t understand their discharge instructions

By Kim Smiley 

Keeping patients as comfortable and safe as possible following hospitalization is difficult if they aren’t receiving appropriate follow-up care after returning home.  But a recent study “Readability of discharge summaries: with what level of information are we dismissing our patients?” found that many patients struggle to understand their follow-up care instructions after leaving the hospital.  

Generally, follow-up care instructions are verbally explained to patients prior to discharge, but many find it difficult to remember all the necessary information once they return home.  The stress of the hospitalization, memory-clouding medication, injuries that may affect memory and the sheer number of instructions can make remembering the details of verbal follow-up care instructions difficult. 

In order to help patients understand and remember their recommended discharge instructions, written instructions are provided at the time of discharge.  However, the study found that many patients cannot understand their written follow-up care instructions.  The study determined that a significant percentage of patients are either functionally illiterate or marginally literate and lack the reading skills necessary to understand their written instructions.  One assessment found that follow-up care instructions were written at about a 10th grade level and another assessment determined that the instructions should be understood by 13 to 15-year-old students.  

One of the causes that contributes to this problem is that discharge instructions are written with two audiences in mind – the patient and their family as well as their doctor.  Many patients need simple, clear instructions, but other doctors understand medical jargon and more complicated care instructions.  

It is important to note that the study did have several limitations.  Researchers did not give patients reading tests and instead relied on the highest level of education attained to estimate literacy skills.  Non-English speakers were excluded.  Even with this limitation, the study provided information that should help medical professionals provide clear guidance on follow-up care recommendations. 

The obvious solution is to work towards writing care instructions that are as simple and clear to understand as possible. In order to help patients clearly understand their follow-up care instructions, the American Medical Association already recommends that health information be written at a sixth grade reading level.  Providing clear contact information and encouraging patients to call their nurse or doctor with any questions about discharge instructions could also improve the follow-up care patients are receiving.

Root Cause Analysis

What’s the best way to screen for breast cancer? Opinions differ.

By ThinkReliability Staff

In 2015, there were 40,000 deaths from breast cancer and 232,000 new cases of breast cancer in the United States. It is the second-leading cause of cancer death in women in the United States. The very high level cause-and-effect is that people (primarily women) die from breast cancer due to ineffective treatment. The later the cancer is detected, the later the treatment begins so early detection can help prevent breast cancer deaths. Currently the best solution for detecting breast cancer is a mammogram. But the matter of when mammograms should occur is based on risk-benefit analysis.

There’s no question that mammograms save lives by detecting breast cancer. This is the benefit provided in the analysis. Lesser known are the risks of mammograms. Risks include false negatives, false positives, unnecessary biopsies, and unnecessary treatment. The radiation that may be used in treatment can actually be a cause of future breast (and other types) of cancer.

On January 11, 2016, the United States Preventive Services Task Force (USPSTF) issued an update of their guidelines on mammogram starting and ending age (as well as other related recommendations). To develop these recommendations, the task force attempted to quantify the risks and benefits of receiving mammograms at varying ages.

For women aged 40 to 49, the task force found that “there is at least moderate certainly that the net benefit is small.” The net benefit here reflects the benefits of screening (~.4 cancer deaths prevented for every 1,000 screened and an overall reduction in the risk of dying from breast cancer from ~2.7% to ~1.8%) compared to the risks of screening. Risks of mammograms every other year for women aged 40 to 49 include ~121 false positives, ~200 unnecessary biopsies, ~20 harmless cancers treated, and ~1 false negative for every 1,000 women screened. The task force determined that in this case, the benefits do not significantly outweigh the risks for the average woman. Thus, the recommendation was rated as a C, meaning “The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences.” (Women who are at high risk or who feel that in their individual case, the benefits outweigh the risk, may still want to get screened before age 50.)

For women aged 50 to 74, the task force found that “there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” The types of benefits and risks are the same as for screening women ages 40 to 49, but the benefits are greater, and the risks are less. For women aged 50 to 74, there are ~4.2 cancer deaths prevented for every 1,000 screened and an overall reduction in the risk of dying from breast cancer from 2.7% to ~1.8%.   Risks of mammograms every other year for women aged 50 to 74 include ~87 false positives, ~160 unnecessary biopsies, ~18 harmless cancers treated, and ~1.2 false negatives for every 1,000 women screened. The task force determined that for women aged 50 to 74, the benefits of mammograms every other year outweighs the risk. Thus, the recommendation was rated as a B (the USPSTF recommends the service).

The task force determined it did not have enough evidence to provide a recommendation either way for screening women over age 74.

Comparing these risks to benefits is a subjective analysis, and some do not agree with the findings. Says Dr. Clifford A. Hudis, the chief of breast cancer medicine at Memorial Sloan Kettering Cancer Center, “The harm of a missed curable cancer is something profound. The harm of an unnecessary biopsy seems somewhat less to me.” To those that disagree, the task force reiterates that personal preference should determine the age screening begins. However, insurers may choose to base coverage on these recommendations. (Currently, private insurers are required to pay for mammograms for women 40 and over through 2017.)

Determining these recommendations – like performing any risk-benefit analysis – was no easy task and demonstrates the difficulty of evaluating risks vs. benefits. Because these analyses are subjective, results may vary. To view the risk vs. benefit comparison overview by the task force, click on “Download PDF” above.

Root Cause Analysis

Shoveling snow really can trigger heart attacks

By Kim Smiley

You may have heard that shoveling snow can trigger a heart attack and studies have found that there is truth behind that concern.  Before you pick up a shovel this winter, there are a few things you should know.

Shoveling can be much more strenuous than many people realize – even more strenuous than running at full speed on a treadmill.  Snow shoveling also tends to be a goal-oriented task.  People want to clear the driveway before they stop and they may push their bodies beyond the point where they would if they were exercising for fitness.

Cold temperatures can increase the risk of heart problems occurring.  When a body gets cold, the arteries constrict and blood pressure can increase, which in turn increases the risk of heart issues.  High blood pressure and a sudden increase in physical activity can be a dangerous combination.  Additionally, it may take longer than normal for emergency help to arrive if it is needed because of snow and ice on the roadways which makes the situation potentially even more dangerous.

If you are young and fit, snow shoveling can be a great workout (and maybe you could help out your elderly neighbors if possible…), but if you are at risk of heart problems, you may want to put some thought into how you attack the problem of clearing your driveway and/or sidewalks.  First off, you should know if you are potentially at high risk.  Studies have found that people over 55 are four times more likely to experience heart-related issues while shoveling and men are twice as likely as women. People with known heart problems, diabetes or high blood pressure are also potentially high-risk.  Anybody who is sedentary is also at a higher risk of heart issues than somebody who exercises regularly.

So what should you do if you are concerned about the risk of heart problems and shoveling?  If possible, you may want to avoid shoveling if there is somebody else who can do it.  If you are determined to shovel yourself, make sure you drink lots of water and dress warmly.  Try to push the snow if possible, rather than shoveling it.  It is also generally better to shovel lots of lighter loads rather than fewer, heavy loads.  If possible, you may want to shovel several times throughout the storm to spread the work out over time. Take frequent breaks and stop immediately if you feel tired, lightheaded, short of breath or your chest hurts. Stay safe this winter!

To see a Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.  A Cause Map visually lays out all the causes that contribute to an issue so that it can be better understood.  This example Cause Map also includes evidence and potential solutions.

Root Cause Analysis

Chipotle Improves Food Safety Processes After Outbreaks

By ThinkReliability Staff

On February 8, all Chipotle stores will close in order for employees to learn how to better safeguard against food safety issues.  This is just one step of many being taken after a string of outbreaks affected Chipotle restaurants across the United States in 2015.  Three E. coli outbreaks (in Seattle in July, across 9 states in October and November, and in Kansas and Oklahoma in December) sickened more than 50 customers.  There were also 2 (unrelated) norovirus outbreaks (in California in August and Boston in December) and a salmonella outbreak in Minnesota from August through September.

In addition to customers being sickened, the impacts to the company have been severe.  The outbreaks have resulted in significant negative publicity, reducing Chipotle’s share price by at least 40% and same-store sales by 30% in December.  Food from the restaurants impacted by the fall E. coli outbreak was disposed of during voluntary closings, and the company has invested in significant testing and food safety expertise.

E. coli typically sickens restaurant customers who are served food contaminated with E. coli. Food ingredients can enter the supply chain contaminated (such as the 2011 E. coli outbreak due to contaminated sprouts), or be contaminated during preparation, either from contact with a contaminated surface or a person infected with E. coli. While testing hasn’t found any contamination on any surfaces in the affected restaurants or any employees infected with E. coli, it hasn’t been able to find any contaminated food products either. While this is not uncommon (the source for the listeria outbreak that resulted in the recall of ice cream products has not yet been definitively determined), it does require more extensive solutions to ensure that any potential sources of contamination are eliminated.

Performing an investigation with potential, rather than known causes, can still lead to solutions that will reduce the risk of a similar incident recurring.  Potential or known causes can be determined with the use of a Cause Map, a visual form of root cause analysis.  To create a Cause Map, begin with an impacted goal and ask “Why” questions to determine cause-and-effect relationships.  In this case, the safety goal was impacted because people got sick from an E. coli outbreak.  A contaminated ingredient was served to customers.  This means the ingredient either entered the supply chain contaminated or it was contaminated during preparation, as discussed above.  In order for a contaminated ingredient to enter the supply chain, it has to be contaminated with E. coli, and not be tested for E. coli.  Testing all raw ingredients isn’t practical.

Chipotle is instituting solutions that will address all potential causes of the outbreak.  Weekly and quarterly audits, as well as external assessments will increase oversight.  Cilantro will be added to hot rice to decrease the presence of microbes.  The all-employee meeting on February 8 will cover food safety, including new sanitation procedures that will be used going forward.  The supply chain department is working with suppliers to increase sampling and testing of ingredients.  Certain raw ingredients that are difficult to test individually (such as tomatoes) will be washed, diced, and then tested in a centralized prep kitchen and shipped to individual restaurants.  Other fresh produce items delivered to restaurants (like onions) will be blanched (submerged in boiling water for 3-5 seconds) for sanitation prior to being prepared.

Chipotle has released a statement describing their efforts: “In the wake of recent food safety-related incidents at a number of Chipotle restaurants, we have taken aggressive actions to implement pioneering food safety practices. We have carefully examined our operations—from the farms that produce our ingredients, to the partners that deliver them to our restaurants, to the cooking techniques used by our restaurant crews—and determined the steps necessary to make the food served at Chipotle as safe as possible.”  It is hoped that the actions being implemented will result in the delivery of safe food, with no outbreaks, in 2016.

To view the impacts to the goals, timeline of outbreaks, analysis, and solutions, please click on “Download PDF” above.  Or click here to learn more.

Root Cause Analysis

The water crisis in Flint, Michigan

By Kim Smiley

The quality of tap water, or rather lack thereof, in Flint, Michigan has been all over headlines in recent weeks. But prior to a state of emergency being declared and the National Guard being called up, residents of the town reported strangely colored and foul tasting water for months and were largely ignored. In fact, they were repeatedly assured that their water was safe.

Researchers have determined that lead levels in the tap water in Flint, Michigan are 10 times higher than previously measured. Forty-three people have been found to have elevated lead levels in their blood and there are suspected to be more cases that have not been identified. Even at low levels, lead can be extremely damaging, especially to young children under 6. Lead exposure can cause neurological damage, decreased IQ, learning disabilities and behavior problems. The effects of lead exposure are irreversible.

The water woes in Flint, Michigan began when the city switched their water supply to the Flint river in April 2014. Previously, the city’s water came from Lake Huron (through the city of Detroit water system). The driving force behind the change was economics. Using water from the Flint river was cheaper and the struggling city needed to cut costs. Supplying water from the Flint River was meant to be a temporary move to hold the city over while a new connection to the Great Lakes was built within a few years.

The heart of the problem is that the water from the Flint river is more corrosive than the water previously used. The older piping infrastructure in the area used lead pipes in some locations as well as lead solder in some joints. As the more corrosive water flowed through the piping, the lead leached into the water.

A Cause Map, a visual root cause analysis, can be built to document what is known about this issue. A Cause Map intuitively lays out the cause-and-effect relationships that contributed to an issue. Understanding the many causes that contribute to an issue leads to better, more detailed solutions to address the problem and prevent it from reoccurring. The Flint water crisis Cause Map was built using publicly available information and is meant to provide an overview of the issue. At this point, most of the ‘whats’ are known, but some of the ‘whys’ haven’t been answered. It isn’t clear why the Flint river water wasn’t treated to make it less corrosive or why it took so long for officials to do something about the unsafe water. Open questions are noted on the Cause Map by including a box with a question mark in it.

This issue is now getting heavy media coverage and officials are working on implementing short-term solutions to ensure safety of the residents. The National Guard and other authorities are going door-to-door and handing out bottled water, water filters, and testing kits. Michigan Governor Richard Snyder declared a state of emergency in Flint on January 5, 2016 which allows more resources to be used to solve the issue. However, long-term solutions are going to be expensive and difficult.

The city’s water supply was switched back to Lake Huron in October 2015, but it will take more than that to “fix” the problem because there is still a concern about lead leaching from corroded piping. Significant damage to the piping infrastructure was done and the tap water in at least some Flint homes is still not safe. It is estimated that fixing the piping infrastructure could cost up to $1.5 billion. A significant amount of resources will be needed to undo the damage that has been done to the infrastructure of the city, and there is no way to undo the damage lead poisoning has already done to the area’s residents, especially the children.