Category Archives: Root Cause

Root Cause

New study finds that cholera vaccine helps protect community

By Kim Smiley

There are an estimated 3 to 5 million cases of cholera worldwide each year, believed to cause more than 100,000 deaths annually.  Cholera is rare in developed nations, but has been pandemic in Asia, Africa and Latin America for decades.  Researchers continue to search for an effective method to prevent cholera outbreaks.  A recent study found that a cheap oral vaccine is an effective tool to help prevent the spread of cholera.  The vaccine is not a perfect solution, but the study found that when two-thirds of the population was given the vaccine, cholera infections in an urban slum were reduced by nearly 40 percent.

The problem of cholera infections can be analyzed by building a Cause Map.  A Cause Map is a visual root cause analysis that intuitively lays out the cause-and-effect relationships of the multiple causes that contribute to an issue.  A Cause Map is built by asking “why” questions and documenting the answers in cause boxes.  To see how a Cause Map of this issue could be built, click on “Download PDF” above.

So why are so many people infected with cholera each year? Cholera is not generally passed from person to person and is predominantly spread through drinking water contaminated with cholera bacterium.  The feces of an infected individual carry cholera bacterium.  Cholera outbreaks occur in areas where there is a person infected with cholera in a location with poor sanitation infrastructure and inadequate water treatment.

Many efforts to reduce the number of cholera cases have focused on providing clean drinking water and providing sanitization equipment.  A recent study looked at three populations in Bangladesh: one was only given the vaccine, the second was given the vaccine, a hand-washing station and taught how to sterilize drinking water, and no intervention was done on the third population. The results showed that the vaccine alone was nearly as effective at preventing cholera as providing the vaccine along with a hand-washing station and instructions on sterilizing drinking water.  In the study, people were given two doses of the vaccine which costs about $3.70.

In an ideal world everyone would have access to clean, safe drinking water, but the resources required to build the needed infrastructure are not likely to be available any time in the near future.  Having a relatively cheap vaccine that is proven to slow the spread of cholera during an outbreak should prove to be a powerful tool in situations where access to clean water is limited.

Root Cause

How One Hospital Improved Heart Attack Care

By ThinkReliability Staff

The heart is responsible for pumping blood through the body, but it also requires blood flow to continue functioning. When the blood supply to the heart is cut off, it’s known as a heart attack and it can be deadly. According to the Centers for Disease Control and Prevention (CDC), about 15% of people who have a heart attack will die from it. Time is of the essence when treating heart attacks. Again according to the CDC, “The more time that passes without treatment to restore blood flow, the greater the damage to the heart.”

Treatment to restore blood flow is generally a balloon (which pushes aside the blockage) and a stent (which holds the artery open). In the United States, this is performed in a hospital. Although hospitals can’t control the amount of time it takes to get a heart attack victim TO the hospital, they can control the time from when a patient enters the hospital until treatment is begun. This is known as the door to balloon (or D2B) time.

A national campaign to improve the speed of heart attack treatment was launched. At that time, the typical heart attack process went like this: a patient suffered a heart attack and (hopefully) 911 was called. An ambulance picked up the patient and delivered them to a hospital. Once the patient arrived at the hospital, an electrocardiogram (EKG) was taken and transmitted to a cardiologist, who determined whether or not the patient was suffering from a heart attack. If it was a heart attack, an interventional cardiologist and other members of the heart attack team were called and made their way to the hospital. The patient was taken through a consent and surgical prep process, and then then balloon and stent were installed. At this time, the national goal was for half of patients to receive a stent and balloon within 90 minutes of arrival at a hospital.

One of the hospitals to take up the challenge was Our Lady of Lourdes Medical Center in New Jersey. In 2007, heart attack treatment was on par or better than other hospitals, with half of patients treated within 93 minutes. (In many locations it took more than 2 hours.) By 2011, treatment time was down to 71 minutes. The head of the cardiovascular disease program challenged the staff to continue to decrease the time and staff members set up a “D2B task force”. This task force looked at each step in the process for potential improvements. Some individual steps were shortened. The forms required for consent were reduced as much as possible. The time spent individually calling in all the members of the cardiac care team was reduced by having a single call ring to all their pagers. Those on the team that were on call were limited to being 30 minutes away from the hospital.

Other steps, instead of being performed one after the other, were performed simultaneously. Instead of waiting for the patient to arrive at the hospital for an EKG, it is taken in the ambulance and transmitted to the emergency room. Each step required for surgical prep is performed as much as possible simultaneously by a team. Additionally, one surgical room is reserved for heart attack patients and is kept stocked with necessary supplies.

Now the median D2B time is 50 minutes. This was demonstrated on March 29, when a patient arrived at the medical center at 1:54 AM and whose D2B time was 55 minutes. This was unusually long for the center. What caused the difference? Because the patient was a 49-year-old woman with ambiguous symptoms, the emergency room doctor waited until the patient arrived at the hospital for another EKG to verify the heart attack before the heart attack team was called.

From 2003 to 2013 the death rate from coronary heart disease has fallen 38%. Some of this drop is attributed to better control of cholesterol and blood pressure, but some is surely due to quicker treatment at most US hospitals.

The “before” and “after” process map that shows the flow of heart attack treatment at Our Lady of Lourdes Medical Center can be diagrammed visually to show how the process flows. To view the process map, the problem outline and timeline of the treatment of the heart attack patient on March 29, 2015, please click on “Download PDF” above. Or click here to read more.

Root Cause

Cuba Eliminates Transmission of HIV from Mother to Child

By ThinkReliability Staff

On June 30, 2015, the World Health Organization (WHO) declared mother-to-child transmission (MTCT) of HIV in Cuba eliminated. Clearly, this is fantastic news. Says Dr. Margaret Chen, WHO Director-General, “Eliminating transmission of a virus is one of the greatest public health achievements possible. This is a major victory in our long fight against HIV and sexually transmitted infections, and an important step towards having an AIDS-free generation.” The fight against HIV continues, with a global target of less than 40,000 new child infections per year by 2015.   (In 2013, there were 240,000 children born with HIV worldwide.) It’s hoped that the progress made in Cuba can be extended to the rest of the world.

How did Cuba do it? Root cause analysis can be used to determine causes of positive impacts as well as negatives. Here we will use a Cause Map, or visual root cause analysis, to determine the causes that resulted in Cuba being declared free of MTCT of HIV. Instead of defining the “problem” in a problem outline, we will define the success using the same format. In this case, the elimination of transmission of HIV from mother to child is the success we’ll be looking at. This success impacts goals as well, though positively. The child safety goal is impacted because it is now very rare (only 2 in 2013) for children to receive HIV from their mothers. The maternal safety goal is impacted because mothers are receiving effective treatment for HIV. Other goals are impacted because of the decreased need for services for children who might otherwise have been infected with HIV.

Beginning with an impacted goal, we can ask Why questions. Why is it rare for children to receive HIV from their mothers? Because the risk of passing HIV from mother to child has been lessened. Why? Because when children are born to HIV-infected mothers, there is decreased exposure to infants from their mother’s bodily fluids, and both mothers and children are being treated effectively for HIV. Decreased exposure to bodily fluids has been accomplished by the use of Cesarean sections and substitution for breastfeeding. Effective HIV treatment results from awareness of the presence of HIV infection from testing performed by healthcare providers, seen as part of a five-year initiative that gave universal healthcare coverage and access. That same access allowed treatment for infected moms and their children with antiretrovirals.

Although this Cause Map is presented as a positive impact to the goals, it could also be presented as an analysis of the problem of HIV transmission from mother to child. The causes would be baby’s exposure to mom’s body fluids, and lack of effective treatment due to lack of knowledge of infection and/or lack of access. The solutions to that Cause Map are the causes presented here in the positive Cause Map. (For example, use of Cesarean sections and substitutions for breastfeeding are solutions to the cause of baby being exposed to mom’s body fluids.)

In order to receive validation from WHO of the elimination of MTCT of HIV, Cuba had to meet very specific indicators for a defined period of time. These indicators do not just measure the overall success of the program (impact indicators), but also measure the success of the initiatives meant to achieve those goals (process indicators). Impact indicators included reducing MTCT of HIV to less than 50 cases per 100,000 live births, less than 5% in breastfeeding populations, and less than 2% in non-breastfeeding populations for at least 1 year. Process indicators included more than 95% of all pregnant women receiving at least one antenatal visit, more than 95% of pregnant women knowing their HIV status, and more than 95% of HIV-positive pregnant women receiving antiretroviral drugs for at least 2 years.

With implementation of similar initiatives across the world, it is hoped that MTCT of HIV will continue to decrease rapidly.

To view the outline, Cause Map, and indicators, click on “Download PDF” above. Click here to read the release from the WHO.

Root Cause

U.S. Teen Dies from Plague

By Kim Smiley

Few people think of the plague as a present-day problem, but a teen boy died of the plague on June 8, 2015 in Colorado.  Officials believe he was bitten by a flea carrying the disease on his family’s farm although the exact source of exposure isn’t known. According to the Centers for Disease Control and Prevention, there are an average of seven cases of plague in the United States a year and a small percentage of these cases result in death.

A Cause Map, a visual root cause analysis, can be built to analyze this case and better understand how a patient died of the plague.  The first step in building a Cause Map is to fill in an Outline with the basic background information to define the issue.  The Outline includes a place to list the impacts to the goals resulting from an issue to help define the scope of the problem.  Focusing on the safety goal for this example, a death would be an obvious impact.  Next, “why” questions are used to build the Cause Map.

So why did the teen die from the plague?  There are two causes that contributed to his death; first, he was infected with the plague and second, he wasn’t treated for the plague.  When there are two causes that both contribute to an issue, both are listed vertically on the Cause Map and separated by an “and”.  So why was the patient exposed to the plague?  Officials believe that he was bitten by an infected flea.  The bacteria that causes plague lives in rodents and their fleas.  Investigators haven’t been able to identify which species of rodent was the culprit.

The teen wasn’t treated for plague because it wasn’t identified that he had the plague until it was too late.  All forms of plague can be successfully treated with antibiotics, but the window for treating the illness before it becomes life-threatening can be relatively short and plague can be difficult to identify.  It is suspected that this patient had septicemic plague which occurs when the plague bacteria enter the bloodstream directly.  Septicemic plague is caused by the same bacteria as the more common Bubonic plague, but the symptoms are different and more difficult to identify.  Rather than the telltale presence of swollen, discolored lymph nodes (also known as buboes) caused by the Bubonic plague, the main symptoms of the septicemic plague are fever, chills and abdominal pain which are very similar to the flu and other common illnesses.  In this heart-breaking case, the family of the teen understandably believed he had the flu and he wasn’t treated for the plague in time to prevent his death.

As alarming as this case is, it is important to note that plague cases in the United States are very rare and occur primarily in two regions – northern New Mexico, northern Arizona, and southern Colorado and California, southern Oregon and far western Nevada. If you are planning to enjoy the outdoors in one of these areas, just remember that the best way to prevent plague is to prevent flea bites.

Click on “Download PDF” above to see a Cause Map and Outline for this example.

Root Cause

Multiple Potential Causes for Avian Flu Outbreak

By ThinkReliability Staff

An outbreak of avian influenza (flu) H5N2 centered around Iowa in the United States has resulted in nearly 47 million birds being killed in 21 states. There is a low risk that this outbreak could spread to humans as the 1996 avian flu did. The impacts on the poultry industry have been significant: the number of birds being killed has led to an increase in poultry prices. Says Phil Lempert, “We’ve lost 10 to 13 percent of the laying hens in this country, so we’re going to have this period of time where we have less birds and less eggs. That means higher prices.”

The financial impact isn’t limited to consumers. The United States Department of Agriculture (USDA) estimates it will spend more than $500 million fighting the outbreak. The impact on poultry producers is expected to be even higher. The USDA Animal and Plant Health Inspection Service (APHIS) is studying the outbreak and attempting to put into place measures that will reduce the spread of the outbreak. Finding the causes leading to the outbreak has proven to be challenging.

We can capture the information that is known in cause-and-effect relationships using a Cause Map to better understand what caused this outbreak. The first step in the Cause Mapping process is to fill in an Outline with basic background information, which includes listing how the overall goals are impacted by the issue. The Cause Map is than built by asking “why” questions to lay out the cause-and-effect relationships. In this example, the animal safety goal is impacted due to the deaths of nearly 47 million birds. These birds were killed because of an outbreak of avian flu. An outbreak results from an initial infection (believed to have been transmitted in this case to domestic flocks by wild birds) and the spread of the disease. Based on genetic analyses from APHIS, this outbreak appears to have multiple independent introductions within the outbreak area (i.e. the transmission from wild birds to domestic flocks happened in multiple locations).

According to their Epidemiologic and Other Analysis of HPAI-Affected Poultry Flocks: June 15, 2015 Report: “APHIS concludes that at present, there is not substantial or significant enough evidence to point to a specific pathway or pathways for the current spread of the virus. We have collected data on the characteristics and biosecurity measures of infected farms and studied wind and airborne viruses as possible causes of viral spread, and conducted a genetic analysis of the viruses detected in the United States.” This means that the cause or causes of the spread of the avian flu cannot be definitively determined due to lack of evidence. When an investigation has a lack of evidence, potential causes are included in the analysis with a question mark, indicating insufficient evidence.

In this case, avian flu was potentially spread by air, by wild birds, and by human movement. Data from APHIS research indicates that the virus has been able to spread on windy days up to a half mile. A solution under consideration is more advanced ventilation systems for poultry farms that would prevent transmission of disease from farm to farm. Previous outbreaks have indicated that wild birds can not only cause an initial infection, but can continue to spread the disease from flock to flock. This evidence supports this cause, but is not strong enough to rule out other causes so all should still be included on the Cause Map. Lastly, APHIS found inadequate biosecurity (primarily cleaning and disinfecting) measures on equipment and personnel that traveled from farm to farm, which could also potentially spread the disease.

The issues found with biosecurity are a particular concern. Says Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, “We used to think we had outstanding biosecurity in poultry. But, except for the outbreak in 1983, which was stopped quickly, we have never been tested before.”

Osterholm and other researchers say more research is needed to screen for viruses, and develop drugs and vaccines to ensure public safety. Although the virus has not yet been shown to infect humans, the Centers for Disease Control and Prevention has developed interim guidelines on testing and treatment. APHIS continues research on how to limit the spread and the USDA, in order to offer some relief on prices, has recently allowed poultry imports from the Netherlands.

To view a Cause Map, or root cause analysis presented in a visual cause-and-effect diagram, of the ongoing outbreak, please click “Download PDF” above.

Root Cause

Contamination found in NIH pharmacy

By Kim Smiley

The National Institutes of Health (NIH) has announced that production of drugs for use in clinical studies has been suspended after fungal contamination was found in two vials of product.  The exact source of the contamination has not been identified, but a recent Food and Drug Administration (FDA) inspection of the facility that prepares the contaminated product found multiple deficiencies, including issues with both the facility and work practices.

This issue can be analyzed by building a Cause Map, a visual root cause analysis that intuitively lays out the cause-and-effect relationships that contribute to an issue. The first step of the Cause Mapping process is to determine how an issue impacted the overall goals.  In this example, the safety goal is impacted because 6 patients were unknowingly given potentially contaminated drugs.  These patients received vials of product from the same batch as the 2 vials found to be contaminated prior to the contamination being identified.  None of the patients have shown signs of illnesses, but they will continue to be monitored. Additionally, the safety goal is impacted because some patients will knowingly be given potentially contaminated drugs.  These patients are due for treatment imminently with no alternative available and the risk of delayed treatment has been determined to be greater than the risk of using the products.  The schedule goal is also impacted as clinical trials are being delayed because the necessary medications aren’t available.

The next step is building the actual Cause Map by starting at one of the impacted goals and asking “why” questions.  So why were the drugs contaminated? It hasn’t been released what specifically lead to the fungal contamination and it may never be known, but the FDA found deficiencies within the facility that could lead to contamination. The inspectors observed workers working with sterile products with protective gear worn inappropriately so that skin and facial hair were exposed.  Issues with the facility itself was also noted, both in the design of sterile work spaces and in the cleanliness of the spaces.  Inspectors determined that the air handling system for the clean rooms wasn’t adequately designed to ensure physical separation from the other spaces.  Additionally, a filter was missing on the air handling system.  The problems with cleanliness of clean rooms included insects found in 2 of 5 clean room ceiling light bays.

The investigation into these issues is ongoing and officials are working to ensure the safety of all products.  As more information becomes available, it can easily be added to the Cause Map.  Once the specific problems with the work processes and facility have been determined, specific solutions can be implemented to address the many issues found by investigators. This problem is one that clearly doesn’t have “one root cause”, but rather many causes that contributed to the problem and more than one solution will be needed to reduce the risk of contamination to an acceptable level.

Root Cause

Care Home Residents Unable to Escape Fire

By ThinkReliability Staff

A tragic fire at a care home for residents dependent on caregivers occurred in Pingdingshan, China on the night of May 25, 2015. Of the 51 residents housed at the 130-bed care home, 38 were killed and 6 injured.

It is tempting to declare the fire as the “root cause” of the tragedy. However, doing so limits the analysis (and thus potential solutions) to only prevention of fires. While many potential improvements in fire prevention at this and other structures with high-risk occupants can be identified, it’s also important to identify solutions that increase the probability of occupants being able to successfully escape a fire.

To ensure that the investigation develops the broadest possible range of solutions, begin with the impact to the goals. In this case, the primary goal impacted was that of resident safety – 38 residents died and 6 were injured. Most residents were unable to escape, impacting the resident services goal. The care home was completely destroyed, impacting the property goal, and it was found to not meet standards, impacting the compliance goal.

Once we’ve determined the impact to the goals, we can develop a Cause Map, or a visual diagram of cause-and-effect relationships that led to the impacted goals. Beginning with one of the impacted goals (in this case the deaths and injuries), and asking “Why” questions develops the cause-and-effect relationships. In this case, the deaths were due to the severe fire at the care home. But that isn’t the only cause. After all, the fire occurred in a facility where 51 residents were (presumably) sleeping, and there were a few residents who were able to escape with their lives.

This means that the cause-and-effect relationship of “fire kills resident” is accurate, but not complete. The effect of the deaths resulted not only from the fire, but from the residents being unable to escape. This gives us two different lines of questioning and possible solutions.

A severe fire results from a fire being initiated and spreading. Heat, fuel and oxygen are required in order to initiate a fire. Oxygen is present in the atmosphere. As in most fires due to destruction of evidence, the heat (or ignition) source has not been identified, but the national work safety agency investigation did find “irregularities” in the electrical system, which could be a potential source. While the initial fuel source is not clear, the care home was constructed with highly flammable materials, which allowed the spread of the fire.

The residents in the care home were dependent on caregivers and so were generally unable to escape without help. Unfortunately help was in short supply. Although residents complained of a shortage of caregivers, it’s not clear how many caregivers were on duty at the time of the fire. Shortage of caregivers is a huge problem in China due to the large percentage of the population that is older, which resulted from the one child policy of previous generations. It’s estimated there are 200,000 caregivers for the elderly in China, and 10 million are needed. In addition, the national work safety agency investigation found that the escape routes in the care home were poorly designed, making it difficult for anyone to escape.

After the tragedy, Chinese Premier Li Keqiang called on others to “draw lessons from the accident, checking all potential safety hazards to avoid similar incidents.” To avoid deaths from fire, that involves not only reducing the risk of fire, but making sure all people, regardless of ability, are able to escape.

To view the analysis of this issue, click on “Download PDF” above. To read about an arson at a care home in Australia that killed 11 and spurred a law requiring installation of automatic sprinkler systems, click here.

 

Root Cause

Identifying and Preventing Causes of Lab Errors

By ThinkReliability Staff

A man was mistakenly told he had HIV. A baby who died from a blood disorder that could have been treated during pregnancy, but wasn’t because the routine blood screen came back clear. A little girl who had to receive a second transplant after the test to verify her acceptance of a new organ was run incorrectly. These are just some of the cases mentioned in a watchdog report about how laboratory errors and weak oversight put patients at risk.

There are 7 to 10 billion medical laboratory tests run in the US every year. Lab tests influence about 70% of medical decisions. Having the wrong information from these tests can be deadly, and there is no good data about how many lab tests may be inaccurate, or may be negitively impacting patient safety. Laboratories are generally overseen by accrediting organizations but the results are almost always private, and there have been recent cases where federal regulators have had to step in because serious deficiencies in lab processes were identified.

The risk isn’t just for patients. An employee was infected with HIV and hepatitis C after a machine malfunctioned, splashing contaminated blood product onto her face. The employee had warned her boss previously that the machine was broken and cross-contaminating samples. Patients can also receive wrong information that isn’t harmful to their physical health but causes all sorts of other problems, such as incorrectly run paternity tests that improperly rule out a man as the father of a child.

The process involved in laboratory testing – from taking a specimen from a patient to delivering the results – is complex, and there are potential issues at each step that can lead to inaccurate results. These causes can be visually diagrammed in a Cause Map, or a visual cause-and-effect diagram. (To view the Cause Map, click “Download PDF” above.) In this case, potential causes of lab errors are captured and analyzed for potential solutions. These causes include labeling of samples, time and storage conditions of the samples, use of proper (and non-expired) products to treat the samples, and calibration of the machines used for the testing.

Actions that reduce the risk of inaccurate lab results should be in place at all labs, but even with a well-planned process, mistakes can happen. That makes the addition of checks and oversight into the process incredibly important. Says Michael Baird, the chief science officer and laboratory director at DNA Diagnostics Center, “I will agree that mistakes are something that can happen whatever you do. You just need to have the appropriate controls in place for when a mistake happens, (so) you can catch it before it goes out the door.”

For example, at the lab Baird runs, samples used for DNA checks are run independently by two different technicians and when a man is ruled out as the father of a child, there is a double-check in place. Other labs have incorporated alert systems for time-sensitive specimens and have hired technical directors responsible for overseeing the labs.

There are also steps patients themselves can take to minimize the impact on their safety from potential lab testing errors. First, ensure that any samples taken are labeled immediately and with accurate information. If you’re at all unsure about a test result, get a second opinion at a different lab. Complaints about a lab should be directed to state health officials.

To view the Cause Map addressing potential causes of laboratory errors, click “Download PDF”. To learn more, read the watchdog report.

Root Cause

Measles Vaccine Provides Multiple Protections

By ThinkReliability Staff

For previously unknown reasons, children who received the measles vaccine were less likely to die from infectious diseases other than measles.   According to Michael Mina, a postdoc in biology at Princeton University and a medical student at Emory University, the difference is significant.  “In some developing countries, where infectious diseases are very high, the reduction in mortality has been up to 80 percent.  So it’s really been a mystery – why do children stop dying at such high rates from all these different infections following introduction of the measles vaccine?”

Based on epidemiological data from countries before and after the measles vaccine was introduced, scientists believe they may have an explanation for this mystery that is part correlation and part causation.  So what’s the difference (and why do we care)?

Correlation means that two or more events tend to occur about the same time and might be associated with each other, but aren’t necessarily connected by a cause-and-effect relationship.  Causation means that a specific action causes a second event to happen.  A cause-and-effect relationship results from causation.   Sometimes it’s very difficult to distinguish between the two.  This is where the importance of evidence comes in.

In this case, part of the decrease in death due to infectious diseases can be considered due to correlation.  In this case, children who received the measles vaccine must have had access to healthcare, including the measles vaccine.  If they received the measles vaccine, they were also likely to receive other vaccines and treatment for other infectious diseases, meaning their death rates from other diseases were also lower.  The measles vaccine did not cause the reduction in deaths from infectious diseases, the access to healthcare did.  Getting the measles vaccine also resulted from the same cause, access to healthcare.

In addition to this correlation, epidemiological data from several countries from prior to the introduction of the measles vaccine shows that the number of measles cases predicted the number of deaths from other infectious diseases two to three years later.  Their hypothesis, supported by studies in monkeys, suggest that the measles virus actually erases immune protection to other diseases.  So, if a child gets measles, he or she loses some of the immune system’s “memory” of how to fight diseases can also be wiped out.  Preventing a child from getting the measles (by getting a measles vaccine) is believed to prevent deaths from other infectious diseases as well.

Although more testing is needed to verify the causation, scientists hope it will provide more evidence for parents to vaccinate their children.  Epidemiologist William Moss, who studies the vaccine at John Hopkins University, says “The reduction in overall child mortality that follows measles vaccination is much greater than previously believed.  I think this paper will provide additional evidence – if it’s needed – of the public health benefits of measles vaccine.  That’s an important message in the U.S. right now and in countries continuing to see measles outbreaks.”

To view the cause-and-effect relationships (both correlation and causation) between the measles vaccine and decreased mortality from childhood infectious diseases, please click on “Download PDF” above.  To learn more about the epidemiological study, click here.

Root Cause

Safely using a treadmill is not quite as simple as it seems

By Kim Smiley

Did you know that treadmills are the riskiest exercise machines?  I sure didn’t, but I have to admit that I have fallen off one before.  (Based on conversations with my coworkers, this isn’t all that uncommon.)  As recent headlines have made clear, using a treadmill safely may not be quite as simple as it seems.

According to data from the National Electronic Injury Surveillance System, about 19,000 people went to the emergency room (ER) because of treadmill injuries in 2009, which is about triple the number of injuries reported in 1991.  More and more people are using treadmills and the number of accidents has increased as well. Although only a small percentage of the injuries are serious, about 30 deaths related to treadmill use were reported between 2003 and 2011.

Understandably, the details surrounding Dave Goldberg’s death have not been released to the public, but it is believed that he slipped while using a treadmill and hit his head when he fell.  Falls off treadmills that result in serious injury are rare, but they have the potential to cause significant injury and even death. More common injuries associated with treadmill use are less serious overuse injuries, such as strains and sprains.

Children are at particular risk of being injured by treadmills.  A motor propels the belt on treadmills and children can get their extremities caught in the moving belt or suffer burns if they accidently turn a treadmill on or one is left running while unattended.  Of the 19,000 ER visits associated with treadmills in 2009, nearly a third were for children under age 9.

So how do you stay safe while using a treadmill?  The number one rule is to limit distractions.  Using a phone or watching TV puts you at a much higher risk of accidently misplacing a foot and falling.  (Trying to write an email while I walked on a treadmill is what resulted in my own fall.  Luckily, only my pride was injured, but I have learned my lesson.)

Treadmills have also risen in complexity and all the buttons and options can be distracting, especially if you are unfamiliar with the specific equipment.  Make sure you understand how to use the treadmill prior to starting the belt.  If you have balance issues or are elderly, you should also check with a doctor prior to using a treadmill.  And lastly, start by walking slowly and gradually increase the pace of the treadmill so that you aren’t caught unaware by how quickly the belt is moving.

To view a Cause Map of this issue, click on “Download PDF” above.