Category Archives: Root Cause

Root Cause

Patient Wakes While Being Prepped for Organ Harvesting

By ThinkReliability Staff

An extremely rare but tragic case has been recently brought to light.  On October 16, 2009, a patient was brought to a hospital center in Syracuse, New York after suffering a drug overdose.  Over the next several days, the patient was in a deep coma, though she did not meet the requirements for brain death based on scans performed at the hospital.   The family was notified and agreed to donate her organs.  The patient, after being sedated, was prepped for donation after cardiac death (DCD).  The organ harvesting stopped prior to any organs being removed when the patient opened her eyes on the operating table.

The hospital was cited not only for the error, but for the inadequate response and investigation after the error was made by the state Department of Health and the Centers for Medicare & Medicaid Services (CMS).  Specifically, the CMS report states “The hospital’s Quality Assurance Performance Improvement program did not conduct thorough reviews of an adverse occurrence involving a patient who was being considered for withdrawal of life-sustaining treatment when she regained consciousness.”

We can examine the error using a Cause Map, or visual root cause analysis, to determine the issues related to the incident.  This provides a starting point for developing solutions to reduce the risk of such an incident recurring, and improving healthcare reliability at this site.

It’s important to frame the issue with respect to an organization’s goals.  In this case, the patient safety goal was impacted due to the risk of patient death from having organs removed.  The accidental removal of organs can also be considered an impact to the patient services goal.  The compliance goal is impacted because of the sanction and fine (though a minimal $6,000) from the Health Department.  Negative press and public opinion as a result of this incident – which was uncovered and reported to the Health Department by the press – is an impact to the Organizational goal.

Beginning with an impacted goal – in this case the Patient Safety goal – asking “Why” questions allows us to develop the cause-and-effect relationships that led to the issue.  In this case, the risk for patient death was due to risk of removing her organs.  The risk for removing organs is because the organ harvesting process had begun.  (The investigation did find that there were no concerns with the organ donation process itself, indicating that errors were prior to the donation prep process.)  The process began because the family agreed to donate organs after the patient was (incorrectly) determined to have suffered cardiac death.

There were a combination of errors that resulted in the patient being incorrectly declared “dead”.  Because all of these factors acted together to result in the impact to the goals, it is important to capture and fully investigate all of them to be able to improve processes at the organization.  In this case, the patient was injected with a sedative, which was not recorded in the doctor’s notes.  It is unclear who ordered the sedative and why.  (It’s also unclear why you would sedate a dead patient, as another doctor stated “If you have to sedate them . . .they’re not brain dead.”)  The patient had previously been in a deep coma due to the drug overdose.  It is possible the coma went on longer than usual because the patient was not given activated charcoal to inhibit absorption of the drugs by the body after the staff was unable to  unable to place a tube.  There appears to have been no additional effort – another area that should be investigated to ensure that protocol is sufficient for patient safety.

The hospital’s evaluation of the patient’s condition before a diagnosis of cardiac death was insufficient.  Specifically, it has been noted that the staff performed an inadequate number of brain scans, inadequate testing to determine the drug levels remaining in the body, and ignored signs that the patient was regaining consciousness prior to preparing her for organ donation.  Because details of these issues were not thoroughly investigated, it’s impossible to know whether the protocols in place at the organization were inadequate for determining cardiac death or whether the protocols were adequate and weren’t followed by staff.

Determining if changes need to be made to protocols as a result of this tragic (though I do want to emphasize rare – the state was unable to find any similar cases in its records) incident is of utmost importance to reduce the risk of an incident like this happening again.  Hopefully the additional scrutiny from the state and CMS will ensure improved patient safety in the future.

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

Root Cause

HIPAA Breach Compromised Data from 187,533 Patients

By ThinkReliability Staff

On July 1, 2013, 187,533 clients of the Indiana Family and Social Security Agency (FSSA) were notified that their medical and financial information may have been accidentally sent to other clients.  Of these, nearly 4,000 may have had their social security numbers disclosed.  Not only is this a breach of the Healthcare Insurance Portability and Accountability Act (HIPAA), it can potentially result in identity theft for those patients affected.

There’s more to this case than initially meets the eye, and many open questions.  We can get our bearings around what is known and what is as yet unknown that may have resulted in issues for patients and the agency involved by capturing the information within a Cause Map, or visual root cause analysis.  Doing so for events that occur can increase Healthcare reliability by delving deeper into related causes, leading to better solutions.

The first step when beginning an investigation is to capture the what, when and where of an incident as well as the impacts to the goals.  If more than one date is relevant, it may be helpful to capture it in a timeline.  In this case, the error was introduced on April 6, 2013.  The error was fixed (at which point the data breach ended) on May 21, 2013.  However, clients were not notified of the potential breach until July 1, 2013.

The impacts to the organization’s goals are those things that prevent an organization from having a perfect day.  In this case, nobody was injured and it’s unclear if there was an impact to employees.  The compliance goal was impacted due to the HIPAA breach.  The organization is impacted because of the breach of patient trust.  Patient services were impacted due to compromised confidential patient information and the potential for identity theft.

We begin with one of the impacts to the goals and ask “Why” questions to develop the cause-and-effect  relationships that led to the impact.  In this case, identity theft is a potential issue because of the compromised patient and financial information, especially social security numbers.  However, the longer the period between the potential breach and when patients are notified, the greater the risk for identity theft.  In this case, from the date that the programming error was incorporated into the system until the patients were notified of the breach was 86 days.  Of this, 34 days elapsed before the error was noticed, but there has been no explanation for the additional 52 days before the notification.  Because the speed of the notification is so important, the “why” here should be addressed in the Cause Map and solutions developed to ensure a speedier notification system in the case of another breach.

We can also ask additional “why” questions to determine how the breach happened in the first place.  Clients were sent confidential health and financial information belonging to other clients.  Though details are sparse, an improperly used variable resulted in an error in the customized coding provided by a contractor to the agency.  How the error made it in – and why it wasn’t found by either the contractor or the agency involved – is unclear.  These are questions that need to be answered during the root cause analysis to reduce the risk of this kind of issue happening again.

The potentially compromising mailing continued for 45 days, increasing the number of people impacted.  (The agency says that because of the way the mailings are done, they have no way to know whose information was actually sent out.)  Of these 45 days, it took 34 days to notice the error.  (How the error was noticed is also not clear but is additional information that should be included in the analysis.)  After the error was discovered, the mailings apparently continued while the error was being fixed for 11 days.  This is yet another line of inquiry to be undertaken during the analysis.  Ideally solutions will help to implement fixes faster – and make sure that breaches don’t continue when a system is known to be working improperly.

In a letter sent to the clients potentially affected, the FSSA stated that the contractor who provides the programming “also is taking steps to improve their computer programming and testing processes to prevent similar errors from occurring in the future.”   While this is certainly necessary, the FSSA should also be looking at their own processes for verifying contractor work and notifying clients in the case of a data breach.

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

Root Cause

Is a Doctor onboard? Management of inflight medical emergencies depends on other passengers

By ThinkReliability Staff

In a recent article, Pierre M. Barker, M.D. describes a terrifying situation – a passenger stops breathing on a plane over the Atlantic Ocean.  Turns out inflight medical emergencies are not that uncommon.  A study published in the New England Journal of Medicine says that about 1 in 600 flights has an inflight medical emergency – for a total of about 44,000 a year, worldwide.  Although the number of people who die as a result of these emergencies is fairly low, the incident that Dr. Barker was involved in indicates there is much room for improvement.

Taking the information from Dr. Barker’s article, we can perform a visual root cause analysis, or Cause Map, of the medical emergency on his flight.  Information gleaned from performing an analysis of one particular incident can provide valuable insight to improving outcomes for similar incidents – in this case, all inflight medical emergencies.

After recording the what, when, and where of the incident (here it’s inflight over the Atlantic Ocean), we capture the incidents to the goals.  Based on Dr. Barker’s description, this situation is aptly described as a “near miss” for patient safety.  What this means is that, had a lot of luck not headed this passenger’s way, he may very well have died on this flight.  We’ll discuss exactly what it is that made it a near miss – and not a fatality – later.   In this situation – and many other inflight emergencies – it seems that the employees are inadequately prepared for medical emergencies.  This is an impact to them – certainly it must be very stressful to have this sort of situation happen on their watch while feeling like there’s not much they can do.   In this case (and occasionally other, similar inflight emergencies), the flight was diverted, an impact to the organization’s goals.  Considering the sick passenger as a “patient” (and this is how I’ll refer to him going forward), the patient services were impacted because the ventilation bag did not connect to the oxygen tank.  Lastly, other passengers were called on to treat the “patient”, which was found to be very typical from the study.  This is an impact to the labor/time goal.

Once we’ve determined which goals were impacted, we can ask “Why” questions to determine which cause-and-effect relationships led to the impacted goals.  In this case there’s a combination of negative impacts and positive impacts – which is how the situation ended up as a “near miss”.  On the negative side, the patient stopped breathing and suffered cardiac arrest.  Because the conditions on a plane are hardly ideal for health, this may contribute to inflight medical emergencies.  There was difficulty in giving the patient oxygen, because the ventilation bag did not connect to the oxygen tank.  Additionally, there was a lack of patient medical history.  The patient was unconscious and there was no health information available which may have aided in his treatment.

The situation described above could have gone very, very badly.  There are some positive causes that contributed as well to make this a near miss.  First, the fact that the patient had stopped breathing was noticed very quickly, because he happened to have Dr. Barker – a pediatric lung specialist – two rows behind him who noticed his difficulty breathing, and then when it stopped altogether.  Because this was not by design but rather a stroke of rather good luck, this is how we get a “near miss”.  After all, you certainly can’t count on a lung specialist tracking the breathing of every person on a plane to stop inflight emergencies.  Not only was the issue noticed quickly it was treated quickly, by Dr. Barker as well as two ER nurses, a surgeon and an infectious disease doctor, as well as a flight attendant who performed a cardiac massage.  This ad-hoc medical team managed to do a heroic job of stabilizing the patient – including use of an AED, which was on the flight, an IV with fluids and glucose, and administration of an aspirin donated by another patient (though according to the study, aspirin should be included in the emergency medical kit on each flight as well).

The flight was diverted – as quickly as possible – to Miami.  This took about two and a half hours, during which time the medical team kept the patient stable until he was transferred off-plane.  This patient was extremely lucky to have these medical personnel aboard.  According to the NEJM study, doctors are present about 50% of time on flights, and the responsibility for treatment of inflight medical emergencies – as well as the decision whether to divert a plane – is generally left up to them.  When an inflight medical emergency occurs and a doctor is not present, the plane is more likely to divert.

As a result of this incident, Dr. Barker has some recommendations on how to make flying safer.  The NEJM study also makes some recommendations.  These solutions are placed directly on the Cause Map, and evaluated for effectiveness.  In this case, creating a standard emergency kit (there is an FAA-mandated emergency medical kit but as seen in this incident, the pieces may or may not work together properly and the kit may be different on different flights) for all flights should be developed.  This kit should ensure that all necessary equipment and medication for the most common and dangerous inflight medical conditions is included and that all flight attendants know where to find and how to put together the necessary pieces of equipment in the kit.  If, as seems to be the case, medical professionals on flights are expected to be responsible for other sick passengers in the case of an emergency, they should be notified as such.  If this occurred, flight attendants would also be aware of where to find these medical professionals.  This could involve a briefing similar to that received by personnel who sit in exit rows.  Where easy diversion is not possible (such as flights over oceans or uninhabited areas), at least one flight attendant should receive EMT training which includes in-depth instruction on how to use the medication and equipment available in the medical kit.  Coordination with onground medical staff should continue, with a focus on trying to make medical history available when possible.

The aviation industry has made flying incredibly safe.  Although inflight medical emergencies are rare and usually non-fatal, the industry now has the opportunity to make experiencing a medical emergency onboard a flight even safer.

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

Root Cause

Common Birth Control Pills Have Increased Risk of Blood Clots

By Kim Smiley

Deaths of 24 Canadian women associated with the use of Yaz and Yasmin birth control pills have been making headlines in recent weeks.  South of the border in the US, more than $1 billion has already been paid out to settle thousands of lawsuits over alleged side effects.  Yaz and Yasmin are drospirenone-based birth control pills that are the most widely prescribed birth control pills worldwide so any concerns with the safety of the medication are alarming.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map lays out the many causes that contribute to an issue in an intuitive way that illustrates the cause-and-effect relationships.  The first step in the Cause Mapping process is to fill in an Outline with basic background information and to determine how the problem is affecting the overall goals of the organization.  In this example, side effects from the pills have been reported to have caused deaths and injuries.    Lawsuits associated with the side effects, specifically blood clots, have cost the drug manufacturer huge amounts of money as well as generated significant negative publicity, neither of which are outcomes a company is hoping for.

The complaints about severe and potentially deadly side effects have been focused on blood clots.  Blood clots are a known potential side effect of using any birth control pills.  It is believed that the estrogen used in birth control pills increases the clotting factors in blood making blood clots more likely.  The reason these specific pills are making headlines is that researchers have found that drospirenone-based birth control pills have a higher risk of blood clots than other birth control pills.  Researchers have estimated that the risk of blood cloths is 1.5 to 3 times higher with drospirenone-containing pills than with some other birth control pills.

For perspective, the FDA has stated that if 10,000 women who are not pregnant and do not use birth control pills are followed for one year, between 1 and 5 of these women will develop a blood clot and for women using birth control pills the range is 3 to 9.  But, and in my opinion this is a pretty big but, it’s worth knowing that the risk of blood clots during pregnancy is estimated to be 5 to 20 out of 10,000 and it’s even higher during first 12 weeks postpartum; estimated to be 40 to 65.

Please talk to your doctor if you have any concerns about blood clots or questions about whether a particular birth control pill is safe for you, especially if you think you may have other risk factors for blood clots.  If you’re curious about the symptoms of a blood clot or about other risk factors you can get more information here.

Please click on “Download PDF” above to see a high level Cause Map of this issue.

Root Cause

Pregnant Patient Dies After Wrong Organ is Removed

By ThinkReliability Staff

A series of errors resulted of the death of a young mother in Romford of the United Kingdom on November 11, 2011.  Details of the patient’s condition and care provided by a  local hospital during a bout of appendicitis were recently released.  We can look at the causes that led to her death – and the death of her unborn baby – in a Cause Map, or visual root cause analysis.

With a complex issue taking place over several days like this one, it can be helpful to develop a timeline to aid in understanding.  In October, 2011, the 5-months pregnant patient entered the hospital and was diagnosed with appendicitis.  Surgery to remove her appendix occurred on October 23rd.  On the 29th, the patient was discharged from the hospital.  The pathology results became available on October 31st. These tests indicated that it was not the appendix that had been removed, but an ovary.  However, the results were not read by any hospital staff at this time.

The patient returned to the hospital on November 7, still in pain.  On the 9th, she suffered a miscarriage, at which point the pathology tests were read.  The patient underwent surgery to remove septic fluid from the diseased appendix, which had not been removed.  Two days later, on the 11th, the patient underwent a second surgery to remove her appendix, and died during the operation.

Before beginning an analysis it’s important to determine which organizational goals were impacted as a result of any issue being analyzed.  In this case, the patient death and miscarriage are both impacts to the patient safety goal.  (Both the mom and baby can be considered patients.)  As a result of the issues related to the patient’s death, eight hospital staff are being investigated, an impact on the hospital’s employees.  The death of a patient related to the wrong procedure being performed – in this case, the wrong organ was removed during her appendectomy – is a “Never event”, which is an impact to the compliance goal.  The Hospital Trust has accepted liability for her death, an impact to the organization.  The wrong organ being removed is an impact to the patient services goal. Additional required surgeries are an impact to the labor goal.

To perform our root cause analysis, we begin with an impacted goal and ask “Why” questions.  In this case, the patient death was due to multiple organ failure.  The multiple organ failure occurred because the patient had sepsis, and the sepsis was not immediately recognized.  (Although it appears that nothing was done to deal with sepsis until two days after the patient returned to the hospital, details on what was done have not been released.)  The sepsis resulted from the patient having appendicitis, and the appendix not being removed for 19 days.  Why was the appendix not removed for 19 days?  Instead of removing the appendix during surgery, the patient’s ovary was removed.  The results of the pathology report (which would have identified that the organ sent was not an appendix) was not read when available.  It is also not clear what the process was for reading these reports at the hospital, and how that process is being fixed.  It is known that the pathologist did not do any special reporting of the adverse results.

Now we get to the question, why was the wrong organ removed in the first place?  The surgeons were attempting to remove the appendix, which was inflamed as the patient was suffering from appendicitis.  Because they were performing open surgery, rather than laparoscopic, and the uterus was in the way of the appendix (due to the pregnancy), the surgery was being performed by feel, rather than sight.  (As you can imagine, this makes the surgery more difficult.)  During the surgery by feel, the ovary was mistaken for the appendix.  The ovary was possibly inflamed, due to the pregnancy, but another important issue is that the surgery was performed with overall inadequate expertise – specifically by trainees with no senior medical staff present.  (Senior medical staff were not required to be present, but due to the admitted difficulty of this type of surgery, that may have been a good move.)

As with many medical mishaps, any number of staff members could have improved the patient’s outcome.  Specifically, though the pathologist was only tangentially involved in the patient’s case, had she or he called the patient’s team immediately upon noticing that what was labeled an appendix was actually an ovary, the patient’s (and baby’s) life would likely have been saved.  Patient safety depends on everyone.

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

Root Cause

Promising New Cancer Drugs Use the Immune System

By Kim Smiley

A promising and potentially powerful new type of cancer treatment uses the immune system to fight tumors.   The drugs are still in early testing, but reports are that they shrunk tumors significantly in 15 to 50 percent of patients.  Patients with different types of cancer have also responded, which is an encouraging sign that the new treatment may have wide spread applications.

A Cause Map, or visual root cause analysis, can help illustrate how these new drugs work and explain why researchers and the companies developing them are so excited about them.  It may seem strange to use a root cause analysis technique on something positive, but it can be just as beneficial to understand why things are going well as it is investigate when problems crop up.  If you understand why a success occurred, the information may be used to reproduce it.   Building a “success” Cause Map is the same as any other Cause Map.  You start by identifying the impacted goals and then ask “why” questions.

In this example, the safety goal was impacted because the new type of cancer treatment shows promise, and the economic goal was impacted because the stock for the companies developing the new cancer drugs rose.   The new cancer treatment being developed shows promise because patients are responding to it and it is completely different from anything being used today.  The new immunotherapy treatments use the body’s own defenses, the immune system, to fight cancer.

You may wonder why drugs are needed at all if the immune system has the ability to fight cancer.  The answer lies in a  cancer tumor’s ability to hide from the T cells, the part of the immune system that detects bacteria and other “invaders”.  Tumors produce a protein on their surface that prevents T cells from detecting them so the immune system never even knows they are there.  A very simplified explanation is that the new drugs block the protein that hides tumors and allow T cells to detect them.   Once detected, the immune system will attack the cancer.

If immunotherapy is successfully developed, it would give doctors more options in treating cancer, especially those that don’t respond to the conventional treatments.  So far the side effects have also been minimal, far less than what is generally seen with chemotherapy and radiation treatments.

Much more research is needed before this type of drug is widely available, but the findings so far are positive enough to increase stock prices and excite experts in the field.   I have my fingers crossed that the end result is everything researchers are dreaming it will be.

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

Concern About a Resurgence of Black Lung Disease

By Kim Smiley 

Did you know that black lung disease has killed 70,000 coal miners since 1970?  Despite regulations designed to protect them, modern coal miners still face very real danger from coal dust.  Changes to the mining industry seem to be exacerbating this long standing issue.

Black lung disease, as coal workers’ pneumoconiosis is colloquially known, is caused by inhalation of coal dust, but there is more to the issue that needs to be understood.  The problem of miners suffering from black lung disease can be analyzed by building a Cause Map, a visual root cause analysis.  Cause Maps lay out the different causes that contribute to an issue visually to illustrate the cause-and-effect relationships.   (To view a high level Cause Map of this issue, click on “Download PDF” above.)

Coal dust is dangerous because it accumulates in the lungs and can cause long-term lung damage and breathing difficulties.  It is irreversible and there is no proven effective treatment.  Death can occur in severe cases.  The only option to fight this disease is prevention.

Black lung disease has a long history and concern about it first came to head in the 1960s.  A strike by 40,000 West Virginia coal miners pushed passage of the Federal Coal Mine Health and Safety Act of 1969.  This legislation limited coal dust exposure to 2 milligrams per cubic meter of air, which was significantly less than most miners were being exposed to at that time.  At first it seemed that the limits were effective in dramatically limiting black lung disease, but some are now worried about a resurgence of the disease.

Some speculate that changes in the mining industry are putting miners at greater risk for black lung disease.  The more dust that miners inhale, the greater the health risk and miners are both working longer hours and using equipment that potentially creates more dust.   The average workweek grew 11 hours since the 1970s which means miners are potentially exposed to dust for hundreds of more hours each year.  Technological advances have resulted in mining technology that is more powerful and can cut through coal faster, which can result in more dust.  The amount of coal produced per hour of work has nearly tripled since the 1970s.  These changes make it more challenging to prevent inhalation of dangerous levels of coal dust.  Increase in demand as well as the rising price of coal has driven these changes because it’s profitable to mine coal as quickly as possible.  Miners are also willing to work in the evolving conditions because mining provides a better living than other jobs available.

One of the most alarming pieces of evidence that cases of black lung may be increasing came from autopsies of the 29 miners killed in the blast at the Upper Big Branch mine in 2010.  The medical examiner was able to test tissue from 24 of the victims’ lungs and he found that 71% of those tested had black lung disease, a truly distressing percentage.  Some of the miners were relatively young and had a limited amount of time on the job.

There is no clear agreement on the best way to prevent black lung disease.  People are still trying to bound the problem and understand how significant the issue is.  But working to understand the problem is always the best first step to trying to solve it.

Root Cause

Health Risks to Young Athletes

By Kim Smiley

Deaths and serious injuries of young athletes make headlines every year.  So how do we ensure that participation in sports is as safe as possible?  The first step is to determine what is causing the deaths and understanding the factors involved.

The serious health risks to young athletes can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map visually lays out all the causes that contribute to an issue to show the cause-and-effect relationships to help illustrate the problem.  According to experts, some of the serious health threats to young athletes are sudden cardiac arrest, heat stroke and concussions.

The potential for concussions, especially in the more physical contact sports, has been getting a lot of attention in the media lately, but the most common cause of death of young athletes is sudden cardiac arrest.  Most cases of sudden cardiac arrest are caused by pre-existing heart conditions and the heart breaking part is that most of these are detectable and treatable.   Most of the heart conditions that cause sudden, unexpected death have few symptoms and can’t be found by a typical sports physical done in the US.  About two-thirds of the dangerous heart defects could be found by an electrocardiogram or EKG test, but these are not routinely done in the US.  The main factor preventing EKGs is the cost, which is not always covered by insurance.  Sudden cardiac arrest is also a risk that many people don’t know a lot about.

Concussions are also a risk for athletes of any age.  Concussions can have long term health consequences and occur when brain cells are damaged.  Concussions are mainly caused by impact to the head, but can also be caused by sudden jolts to the body that cause the brain to hit the inside of the skull.  Impacts during contact sports are a well-known cause of concussions, but typical sports activities like heading a soccer ball can also cause concussions.  Wearing the appropriate safety gear can help prevent concussions.  The rules of some sports also limit the more dangerous plays like helmet to helmet tackles in football.

Another significant risk to young athletes is heat stroke.  Heat stroke is usually preventable, but is still a significant risk and can cause death in extreme causes.  Heat stroke occurs when the internal temperature of the body rises above safe levels.  Young athletes are susceptible to heat stroke because many sports practice outside in hot weather. The typical modern, air conditioned life style increases the risk of heat stroke because athletes are generally less acclimated to the heat at the start of the season.  Athletes are most likely to suffer from heat stroke during the first few days of practice in hot temperatures. Gradually increasing workouts in warm temperatures to allow athletes to acclimate to the weather has been very effective at preventing heat stroke. For example, heat stroke rates dramatically decreased after the NCAA limited practice to three hours once a day for the first five days.

How quickly treatment is administered can also dramatically change the outcomes if an athlete is injured.  Quick action by trained personnel with the appropriate equipment can save lives.  According to a recent New Times Times article, only about 40 percent of high schools in the United States have a certified athletic trainer on staff and only about 70 percent have an automatic external defibrillator (AED).  AEDs are important because they can improve the chance for survival after sudden cardiac arrest by 60 percent or more.

So what is the best way to keep our young athletes safe?  This is a matter of lively debate.  Some people believe that the right answer is to require EKGs during pre-participation physicals, but the cost of performing EKGs on the 7.7 million high school athletes in the US is not trivial.  There is also the issue that EKGs, like most diagnostic tests, are not perfect and produce some false positives that would require more testing that raises costs.  Some believe the money could be better spent by hiring more trainers and buying more AEDs.  The answers aren’t simple, but the better we understand the problem the more informed the decisions will be.