Category Archives: Root Cause

Root Cause

Confusion over Electronic Health Record Entry Leads to Death

By ThinkReliability Staff

A woman seen at an Illinois emergency room for a puncture wound from a gardening tool died of tetanus. Tetanus has a high fatality rate and there is no cure once it is developed, but the tetanus vaccine provides high levels of protection, even when given after a wound is sustained.   (Tetanus generally takes several days to incubate after a puncture wound that delivers the C. tetani spore, caused by an object that may have been exposed to feces, such as any object outdoors.)

Upon receipt of a threatening puncture wound, it is recommended that a patient be given a tetanus booster if it has been more than five years since an immunization has been given. It is unclear when the woman had last had a tetanus booster, but if status is unknown, giving a booster is also recommended. Despite coming to the emergency room for a puncture wound that was threatening with an unknown immunization status, the woman did not receive a tetanus shot. We can look into the details of the case in a Cause Map, or root cause analysis. This format diagrams the cause-and-effect relationships that led to an issue – in this case, the death of a patient from tetanus despite seeking treatment from a hospital.

In this case, the woman died of tetanus because she was infected with tetanus by being stabbed with a garden fork (for reasons which are unclear), and because she was not effectively immunized against tetanus. The patient was ineffectively immunized because she did not receive the recommended tetanus immunization.

During the patient’s intake by a nurse, the immunization status in the patient’s electronic health record (EHR) was selected as “unknown/ past 5 years”. The physician treating the woman did not request any clarification, but apparently considered that her shots were up-to-date and did not order a booster. This clearly indicates a poor design in the EHR as an “unknown” status would indicate the need for a booster, and having a shot within the “past 5 years” would not.

This confusion illustrates the issues being seen during the increased use of electronic health records. In their report Health IT and Patient Safety: Building Safer Systems for Better Care by the Institute of Medicine, they state, “designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences.” A review by a medical malpractice insurer showed that EHR issues were involved in only 1% of lawsuits concluded from 2007 to 2013 but that percentage had doubled from 2013 to early 2014, and more are expected with the increased adoption of EHRs. This is disappointing news for an incentive program for the use of EHRs, which hoped they would make hospitals safer. Data on whether or not that has occurred is mixed.

Because of their concerns, the Institute of Medicine has recommended the creation of an information technology (IT) safety center to investigate EHR risks. So far the proposal has not been funded by Congress. Others think that a government-supported fund to compensate victims, similar to that used for vaccine injuries, may be necessary.

The Office of the National Coordinator for Health Information Technology has released a guide on identifying and addressing unsafe conditions associated with health IT (available by clicking here). It calls for providers, EHR developers and policymakers to ensure health IT is used to improve patient care and protect patient safety.

To view the Cause Map of the tetanus death, please click on “Download PDF” above. To learn more about identifying and addressing unsafe conditions associated with health IT, click here.

 

Root Cause

Listeria in Ice Cream Causes 3 Deaths

By ThinkReliability Staff

On April 20, 2015, the Centers for Disease Control and Prevention (CDC) announced a recall of all Blue Bell Creameries products due to possible contamination by Listeria monocytogenes.  While the company has not yet determined the source of the outbreak, they are working with outside agencies to determine potential causes and implementing solutions to reduce the risk of food-borne illness in the future.  Says Paul Kruse, the CEO and president, “We’re committed to doing the 100 percent right thing, and the best way to do that is to take all of our products off the market until we can be confident that they are all safe.  At this point, we cannot say with certainty how Listeria was introduced to our facilities and so we have taken this unprecedented step.  We continue to work with our team of experts to eliminate this problem.”

Performing a root cause analysis can help clarify the goals of an investigation, determine the causes of the problem(s) related to an issue, and provide ideas for action items to reduce the risk of the issue recurring.  We can gather the information known so far about the outbreak in a Cause Map, or visual root cause analysis.

The Cause Mapping process begins by capturing the what, when and where of an incident.  Here, the “what” is the Listeria outbreak.  The “when” in this case is believed to have started in 2010 and continued to the present.  It can be helpful to capture any noted differences about the particular investigation.  For example, most outbreaks don’t last 5 years.  The use of genome sequencing (starting in 2013) allowed investigators to tie Listeria cases from 2010 on to this particular outbreak.  An additional difference is that Listeria can replicate in very cold temperatures.  This is unusual because freezing foods generally reduces the risk of propagating food-borne contamination.  The “where” is across the US – all products have been recalled and all plants have been shutdown, with several having been implicated in spreading Listeria.  Another useful piece of information can be the task being performed.  In this case, the contamination was discovered during random sampling.

The next step is identifying the impacts to the goals.  For this incident, the safety goal was impacted due to the sicknesses and deaths.  The outbreak of Listeria can be considered an impact to both the environmental and customer service goal, while the loss of production (no Blue Bell products are currently available or being produced for consumers) is an impact to the production goal.  The disposal of the estimated 8 million gallons of ice cream covered by the recall impacts the product goal, and the response and investigation impacts the labor goal.

The analysis step begins with an impacted goal.  Asking “why” questions develops the cause-and-effect relationships that led to the impacts.  In this case, the sicknesses and deaths were caused by a Listeria outbreak.  In order to have a food-borne illness outbreak, the food needs to be contaminated AND it needs to be delivered to consumers.  In this case, the contamination was not known because ice cream is not tested for Listeria.  There is no history of Listeria outbreaks in ice cream and testing is difficult on perishable products because of the time required.  Once ice cream products are again manufactured for consumers, Blue Bell has said it will implement a test and hold process (holding product until testing comes back negative).

The Listeria contamination results from the introduction of Listeria into the ice cream.  As discussed before, Listeria can replicate in cold temperatures.  The contamination source is likely surfaces in the production facilities or cross-contamination from other food products.  Because multiple plants are contaminated and cleanliness issues have been a concern in the past, it is likely that the outbreak is due to contamination of surfaces, on which Listeria can remain for a long time if not properly sanitized.

In addition to the test and hold process, Blue Bell is in the process of implementing a number of other changes to reduce the risk of future contamination.  Employees are being trained in microbiology and an expanded cleaning and sanitation program.  Prior to production resuming, equipment is being disassembled, cleaned, and tested for contamination and design changes that would make cleaning easier (reducing the risk of future contamination) are being considered.

While it is sometimes difficult to determine the success of solutions, the test and hold process to be used for future ice cream products should provide almost real-time feedback on the success of the programs and ensure that future problems are quickly identified.

To view a one-page PDF of the analysis and solutions, please click on “Download PDF” above.  To learn more about the ice cream Listeria outbreak, click here.  To read our previous blog about the 2011 fatal Listeria outbreak in cantaloupe, click here.

Root Cause

With $16.3B, Why Are Veterans Still Waiting for Care?

By ThinkReliability Staff

Concerns regarding the timeliness of treatment within the Veterans Administration (VA)’s network of hospitals and clinics have been around nearly as long as the VA itself. In 1995, a goal was set to have veterans seen for appointments within 30 days. VA doctors’ and executives’ bonuses are based at least in part on meeting timeliness targets. Many believe this is a key reason that waiting lists were doctored (by being kept on a separate “secret” waiting list, before being moved onto the real, computerized waiting list within 14 days of their scheduled appointment). The scandal, which is believed to have contributed to the deaths of dozens of veterans while they waited for appointments, led to much consternation and a call for significant reform to improve the waiting time of veterans.

It was found that veterans were waiting too long for appointments not only in Phoenix (where the “secret waiting list” scandal was discovered) but at many VA sites around the country. This was determined to have significant (though not always easily quantifiable) impact on patient safety as well as patient services to the large numbers of veterans who were unable to get timely appointments. (Read our previous blog about a veteran who lost much of his nose after waiting more than 2 years for a biopsy.)

In order to lessen the waiting times, $16.3 billion in spending to hire more doctors, open more clinics, and create a program that allows veterans to seek private-sector care was approved July 31, 2014. However, a study by the Associated Press has found that from August 1, 2014 to February 28, 2015, over 890,000 appointments failed to meet the timeliness goal. More than 230,000 appointments were delayed more than 60 days. While the number of vets waiting more than 30 and more than 60 days has stayed about flat, the number of appointments that take more than 90 days has nearly doubled. Some specific problem areas have been identified.

Challenges remain with the “Choice Program”: The Choice Program began to cover non-VA care for eligible veterans November 5, 2014. However, eligibility remains limited to those who have to wait more than 30 days from their “preferred date” or a date medically determined by their doctor or those who are more than 40 miles (straight line) from the nearest VA facility or face an unusual travel burden to access it.   Only some private physicians participate. The program is being expanded so that the 40 miles is based on driving distance rather than a straight line calculation, and telephone lines and other programs are being implemented to assist veterans using the program to seek care.

Medically underserved areas have the worst delays: During the government’s investigation, it was found that many VA facilities have inadequate providers for the number of veterans in their care. These areas tend to be areas that are medically underserved, which compounds the problem because civilian options in the area are also limited, limiting the effectiveness of the program that allows veterans to seek private-sector care. Says Dr. Kevin Dellsperger, chief medical officer at Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa, “Not a lot of medical students want to go work for the VA in a rural community medical clinic.” While 8,000 employees were added to the VA between April and December 2014, it’s hoped that increasing salaries in the underserved areas will attract more providers.

Physical space is also an issue: Any government contracting and building process can be cumbersome, and the VA has been identified as having particular difficulty managing the contracting process. When buildings are (finally) constructed, they’re usually already too small.

Enrollment is increasing: Enrollment in VA programs has been expanding rapidly. From 2002 to 2013, enrollment increased from 6.8 million to 8.9 million and spending increased from $19.9B to $44.8B.   Says Robert McDonald, Secretary of Veterans Affairs, “Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care.” It’s hoped that the increased enrollment is actually a positive, buoyed by the efforts made to increase access and shorten waiting times. “I think what we are seeing is that as we improve access, more veterans are coming, ” says Sloan Gibson, the Deputy Secretary of Veterans Affairs.

It may get worse: “The cost of fulfilling those obligations to our veterans grows and we expect it will continue to grow for the foreseeable future. We know that services and benefits for veterans do not peak until roughly four decades after conflict ends . . . we project the benefits for recent veterans in recent conflicts will peak around 2055,” testified VA Secretary McDonald.

The VA administration is asking for patience. Deputy Secretary Gibson says “We are doing a whole series of things – the right things, I believe – to deal with the immediate issue. But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

To view an overview of these issues in a visual cause-and-effect diagram (or Cause Map), as well as some of the associated solutions, click on “Download PDF” above. To read more about the AP’s analysis, click here.

Root Cause

Prisoner escapes from hospital

By ThinkReliability Staff

A recent prisoner escape from city custody in Virginia was only one of four attempted escapes in the US over 8 days related to seeking medical care.  Examining the cause-and-effect relationships shows what led to the prisoner escape and can provide insight into improvements to reduce the risk of it happening again.  These cause-and-effect relationships can be diagrammed visually in a root cause analysis, or Cause Map.

The analysis begins by capturing the what, when and where of the problem.  In this case, the issue being analyzed is the escape of a prisoner from a public hospital in Alexandria, Virginia March 31, 2015 at about 3:00 a.m.  Along with the where, we capture what was happening at the time.  In this case, the patient was receiving medical care after a suicide attempt.  It’s also helpful to capture any differences.  Differences could be in the location, date, time or task being performed.  In this case, a few things stand out from a summary reading of the media reports available.  First, the city jail prisoner was being treated at a public hospital, and second, one of the guards responsible for the prisoner was taking a bathroom break.

These differences may or may not be causally related to the issue, but provide potential causes to consider. As mentioned, there were four prisoner escapes during a week related to medical care.  On the same day, a New Orleans prisoner escaped from a van transporting prisoners to a hospital.  The previous day, a New Jersey prisoner escaped from a hospital, and a week prior, a West Virginia psychiatric hospital patient facing murder charges escaped.

As physical and procedural security at prisons improve, fewer prisoners are escaping from the facilities themselves.  Many times, being removed for medical care is the best opportunity.  Federal prisons, which provide on-site medical care, have far fewer escapes than other facilities.  From 1999 to 2001, only one of 115,000 federal prisoners escaped.

A single trip for medical treatment itself may not be to blame for the escape attempts, but repeat trips to the same medical facility may increase the risk.  Says Kevin Tamez, inmate advocacy consultant, “Very rarely do these guys go to the hospital for treatment and all of a sudden they decide they’re going to escape.  What happens is, traditionally, inmates go to the hospital for treatment . . . they come back to the facility and they start telling other inmates . . . There is nobody more ingenious than an inmate.  They have nothing to do all day but sit around and think things up. There are ways of minimizing it, but there’s never a way to prevent it.”

Having only one guard instead of two, due to a bathroom break, is problematic for obvious reasons.  It’s far more difficult to overwhelm two guards than one.  “From a safety perspective it’s always good to have two people there,” says Gary Klugiewicz, a consultant/ trainer for law enforcement & correctional officers.  The amount of time the guards were watching this prisoner at the hospital (4 days, for reasons that are unclear) may have also played an impact.  It’s hard to keep your guard up for that amount of time.

The U.S. Marshals, who had responsibility for the prisoner at the time, will be reviewing their procedures to look for opportunities for improvement.  Experts suggest that enlisting hospital security to fill in, rather than leaving just one guard in place, may help.  Because the secure healthcare facilities in federal jails allow so many fewer escapes, using these instead of public hospitals may reduce the risk of escape.  However, there’s still the problem of transporting inmates, which is another high escape potential.

To view the Cause Map of the prisoner’s escape, click on “Download PDF” above.  Or click here to learn more.

Root Cause

Disabled resident dies when caregiver falls asleep

By ThinkReliability Staff

A physically disabled resident in a New York state-run care home required checks every two hours to ensure he was receiving adequate oxygen.  On the night of September 10, 2013, his nurse fell asleep, and he went more than 8 hours without the checks.  During this time, his oxygen level dropped to 40% (anything below 90% is considered dangerous), and he later died of hypoxic brain injury.

Says Patricia Gunning, prosecutor for the New York State (NYS) Justice Center for the Protection of People with Special Needs, “This case serves as a tragic reminder of the serious risk posed by an all too common workforce problem of caregiver fatigue or workers sleeping on shifts.”

Sadly, “all too common” turned out to be all too true.  The NYS Justice Center for the Protection of People with Special Needs was formed in mid-2013, and oversees agencies responsible for more than a million people in state care or state-funded nonprofits.  During its first year, it found 458 reports alleging abuse or neglect that cited a caregiver sleeping on the job.  This included caregivers who slept through a resident’s grand-mal seizure and a resident’s elopement, residents with unattended access to medications and food, and residents who were in a car driven by a caregiver who fell asleep at the wheel.

Even with a seemingly overwhelming problem such as this, progress can be made by looking at the specifics of one case, identifying causes that led to the problem, and developing solutions.  These solutions can then be considered for individual or widespread application.  We will examine the specifics of this case in a Cause Map, or visual root cause analysis, which lays out the cause-and-effect relationships leading to a problem.

The problem being examined is determined by the impact to an organization’s goals.  In this case, the resident safety goal was impacted because of the death of the resident.  The resident services goal was impacted because the resident did not receive adequate oxygen.  The compliance goal is impacted because of the felony charges against the nurse, who was sentenced to 90 days in prison.

Beginning with the most prominent impacted goal – in this case the resident safety goal – and asking “why” questions develop the cause-and-effect relationships that led to that impact.  In this case, the resident died from hypoxic brain injury (per diagnosis), from a lack of oxygen.  Due to the resident’s physical disability, his oxygen delivery equipment was required to be checked every 2 hours around the clock.  On the night of September 10 to September 11, more than 8 hours passed between checks, at which point the patient was found unresponsive.  (He died two weeks later.)

The resident’s oxygen delivery was not checked for more than 8 hours (as opposed to the required two) because the caregiver on duty had fallen asleep.  Testimony from the nurse in question as well as others from the facility describing sleeping on overnight shifts as a common occurrence.  Later research from the NYS Justice Center for the Protection of People with Special Needs found that many incidents involving caregiver sleeping on duty involved staff working extended or otherwise non-traditional work shifts.  The nurse who fell asleep on duty worked 12-hour night shifts at a site where many signed up for overtime and just barely passed duty hour requirements.

In response to the numerous caregiver sleeping events it discovered, the NYS Justice Center for the Protection of People with Special Needs has provided a toolkit aimed to protect people with special needs from caregiver fatigue.  The Center recommends that care provider agencies implement & regularly review policies meant to deter and detect sleeping on the job, establish contingency plans to relieve staff found unfit for duty, and provide assistance to residents in calling for help if caregiver is unresponsive.  Due to the myriad issues associated with caregiver fatigue, the American Nurses Association (ANA) continues to fight to reduce nurse fatigue, and possible harm to patients.

To see a one-page PDF with an overview of the investigation related to the resident lack of oxygen due to caregiver sleeping, click on “Download PDF” above.  Or, click here to learn more.

Root Cause

What Caused an HIV Outbreak in Rural Indiana?

By Kim Smiley

A public health emergency has been declared after 79 cases of HIV were confirmed in rural Indiana, the worst outbreak of HIV the state has ever seen.  Individuals potentially at risk have been encouraged to get tested and the number of cases is expected to rise as more cases are identified. The epidemic has been tied to intravenous drug use, although other risky behaviors may also have spread the disease.

In order to effectively fight this HIV epidemic and hopefully reduce the risk of outbreaks in the future, the factors that have led to these HIV cases needs to be understood. This region has been struggling with the use of Opana, a powerful opioid painkiller, for years.  Opana is commonly injected and health officials believe that the use of dirty needles has been the primary driver of HIV infections although unprotected sex was also a potential pathway for infection for some.  Needle exchange programs are illegal in Indiana and access to clean needles is limited so needles are being shared.  In an environment where needle sharing is common, it takes only one individual infected with HIV to rapidly spread the virus to many other drug users.

HIV is also more likely to be spread if infected individuals are unaware that they are infected and are not being treated.   Identifying an individual who has contracted HIV as early as possible and providing treatment helps prevent the disease from spreading because an HIV-positive person who receives sustained treatment is drastically less infectious, even if they continue to engage in high risk behaviors. Access to healthcare and HIV testing is limited in this region where many residents are uninsured and may lack transportation. Heroin use has long been tied to HIV, but users of Opana (a licensed pharmaceutical) may not have been fully aware of the potential risk from sharing needles.

Now that the HIV epidemic has been identified, healthcare officials are working to reduce the risk of more infections by providing testing and treatment.  One physician is even driving door to door, offering free HIV testing and trying to educate residents on drug addiction and HIV treatment.  Austin, Indiana has established its first ever HIV clinic to provide testing, counseling and treatment.  Targeted resources to help educate residents on drug use and to assist addicts seeking to get clean are also being provided.  The governor of Indiana has approved a short term needle exchange program.  Indiana has also created a public awareness campaign to help inform people about the risks of intravenous drug use.  Drug addiction is a notoriously difficult problem to battle, but the additional resources should help reduce the rate of future HIV cases.

To view a high level Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.

Root Cause

Hospital reduces neonatal fatalities by 50%

By Kim Smiley

Infant mortality rate is often used as an indication of a nation’s health and social condition.  When reviewing the data for different countries, it becomes obvious that for a wealthy, developed country, the United States has a high infant mortality rate. According to the CIA World Factbook, the US infant mortality rate is 6.2 deaths per 1,000 births, which is nearly twice that of France, Italy and Spain. Additionally, the US ranked 60 for maternal deaths in a study for the Institute for Health Metrics and Evaluation.

The good news is that healthcare providers are working to improve care and help reduce preventable injuries and deaths during childbirth.  Obviously, access to prenatal care, overall health of the mother and other factors play a role in birth outcomes, but some relatively simple solutions targeting labor and delivery care have proven to dramatically increase birth outcomes.  A new report “Solutions in Sight” by the nonprofit Public Citizen lists some of the successes in improving birth outcomes.

One particularly impressive case is that of Ascensions Health, which reduced its neonatal fatality rate by 50% across its 43 hospitals by implementing relatively cheap, common-sense solutions.  Ascension did a number of things to help improve birth outcomes such as improving training and communications.  Drills were done to practice how staff should respond in a variety of emergency situations to help medical personnel identify and quickly respond to potentially dangerous scenarios.  There was also focus on communication between personnel to help ensure there were no misunderstandings in high pressure situations and to encourage all staff members to speak up if they perceived a dangerous situation.

Additionally, they worked to develop “bundles” of services, which are packages of procedures that have been shown to produce the best results.  Bundles are essentially guidelines for how staff should respond in a variety of situations.  There was also an emphasis on reducing C-section deliveries that weren’t medically necessary because these types of births are associated with a higher rate of complications. None of these solutions were earth-shattering, but they have proven effective when consistently implemented.

In additional to the clear benefit of saving lives and reducing the number of potentially life-long injuries, improving birth outcomes has economic benefits.  Better birth outcomes reduce the likelihood of expensive lawsuits. This example is a classic win-win where doing the right thing actually saves money in the long run as well.

Many of us do not spend our days delivering babies, but this example has many lessons that can be applied across industries.  Learning how to provide effective, realistic training can dramatically improve performance.  Empowering employees at all levels to speak up when something doesn’t look right can save lives, whether it’s in a factory or a hospital.  Formally documenting and using best practices so employees can benefit from others’ experience can streamline many processes and reduce preventable errors.  Sometimes the simple solutions really are the most effective.

Typically, a Cause Map is built when something has gone wrong, but it can also be used as a proactive tool to help understand why something has gone right.  To view a high level Cause Map of this example, click on “Download PDF” above.  Another example of a proactive, positive Cause Map is the Miracle on the Hudson, where all passengers survived a plane landing on a river.

Root Cause

After Patient Death, CMS Surveyor Declares “Immediate Jeopardy” To Patient Safety

By ThinkReliability Staff

From the moment a patient arrived at an endoscopy clinic in New York on August 28, 2014, things didn’t follow the usual procedure.  The patient brought her own ear, nose and throat physician (ENT) to accompany her into surgery for an esophagogastroduoudenoscopy (EGD), though the ENT did not have privileges at the facility.  The patient signed a consent form for anesthesia, and the EGD and her vital signs were taken, though it appears her weight was either not taken or not recorded.

After a time out that was initiated by the endoscopy technician (as opposed to the anesthesiologist, as required by policy) for the EGD, the patient was administered Propofol for sedation.  After the patient was sedated, the ENT attempted to perform a nasolaryngoscopy, despite not having facility privileges or a record of patient consent, but the initial attempt appears to have been unsuccessful.  After the EGD was completed, the ENT performed another nasolaryngoscopy beginning at 8:28 AM and ending (per interview records) at 8:30 AM.

By that time, the patient’s condition was quickly deteriorating.  Her blood pressure had dropped from its pre-procedure level of 118/80 to 84/40, her pulse from 62 to 47, and oxygen saturation from 100% to 92%.  Both the Cardiac Arrest Record and the Endoscopy Code Blue Record indicate that at 8:28 AM (the same time the second nasolaryngoscopy was beginning) the patient went into cardiac arrest/ ventricular tachycardia and measures were taken for resuscitation (including assisted ventilation, chest compressions, and administration of epinephrine and atropine).

The record of the surgery note that the laryngoscope was withdrawn at 8:30 AM, at which time cardiopulmonary resuscitation (CPR) was undertaken.  The patient was resuscitated and transferred to a hospital, where she died on September 4, 2014.  The cause of death from the autopsy report was anoxic encephalopathy (brain damage) caused by hypoxic cardiac arrest (oxygen deprivation).

The day prior to the patient’s death, a surveyor from the Centers for Medicare and Medicaid Services (CMS) declared “Immediate Jeopardy” due to “significant findings . . . which compromised patient safety”.  Specifically, the surveyor noted that the facility had risked patient safety by allowing a doctor without privileges to be allowed in the operating room and perform a procedure, and not obtaining consent or performing a time out for a procedure that was performed.

The facility quickly submitted a corrective action plan that revised procedures allowing visitors to the facility, ensuring informed consent and time out procedures are used before every procedure, and providing training on these updated procedures to staff.  Immediate jeopardy was removed on 9/5/14, although the facility was still considered out of compliance with CMS requirements, and was given until March 2 to maintain its certification.  (CMS has not released whether the facility has been successful.)

A lawsuit is underway that may provide more detail as to how the CMS findings caused (or didn’t cause) the patient’s death.  At this point, what is known can be captured in a timeline (for a chronology of events) and a Cause Map (to capture the cause-and-effect relationships that led to the impact to the goals) to start organizing and presenting information logically.  As more information is available, the Cause Map can be updated.

To see the timeline and initial Cause Map, click on “Download PDF” above.

 

Root Cause

This year’s flu vaccine only about 23% effective

By Kim Smiley

According to the Centers for Disease Control and Prevention (CDC), the flu vaccine for the 2014-2015 flu season is only about 23% effective among people of all ages.  While the flu vaccine is not perfect, the effectiveness is generally closer to 60% percent.

So what made this year different?  Why is the flu vaccine so much less effective than what has been previously observed?  The short answer is that creating a flu vaccine is not an exact science and that the experts’ best guess of which flu strains would be the most common wasn’t as good this year.

One of the reasons that a flu vaccine is needed each year while many vaccines (like the MMR vaccine) aren’t is that the flu virus changes relatively quickly.  The strains of flu that are circulating generally morph from year to year and a new vaccine is needed to protect against them.  The lag time inherent in developing a new vaccine also makes attacking this moving target  difficult.  It just takes time to develop a new vaccine that needs to be tested, manufactured and distributed to millions of people.  Companies need about six months to manufacture vaccines in the quantities required so the process of developing a new flu vaccine begins long before the predicted start of the flu season.

Every year there are hundreds of different strains of flu circulating and flu vaccines contain antigens for only 3 or 4 specific strains. Deciding which strains to include in the vaccine each year is not a simple cut and dry decision. Scientists monitor which strains of flu are circulating worldwide and use that data to select which strains to include in the vaccine, but it is difficult to predict how the virus will change months out.  The button line is that sometimes the flu virus changes unexpectedly and the vaccine ends up being less effective, as it did this year when the specific type of H3N2 virus included in the vaccine morphed after the development of the vaccine.

The question of how to prevent a similar problem in the future is tricky and doesn’t have simple answers.  There are scientists working to develop antigens that would respond to a part of the flu virus that doesn’t change, which could potentially lead to a longer lasting flu vaccine.  Until then the best way you can protect yourself is to get the flu vaccine each year. The CDC still recommends people receive the vaccine this year, even with the lower effectiveness, because it does offer some protection against the flu.

And wash your hands often with soap…that is always the simplest way to reduce the spread of disease.

To view a high level Cause Map, a visual root cause analysis, of this issue, click on “Download PDF” above.

Root Cause

VA works to save nurses’ backs

By ThinkReliability Staff

More than 35,000 nursing employees suffer back and other injuries every year that impact their ability to perform their jobs.   Their rate of musculoskeletal injuries is about three times that of construction workers.

The commonly taught “proper” lifting techniques and sharing the lift with other employees doesn’t help.  Says William Marras, director of The Ohio State University’s Spine Research Institute, “The bottom line is, there’s no safe way to lift a patient manually.  The magnitude of these forces that are on your spine are so large that the best body mechanics in the world are not going to keep you from getting a back problem.”

Armed with these findings, and some studies of their own, the Department of Veterans Affairs (VA) is leading the way in preventing these types of injuries.  The VA discovered that at least $22M (believed to be underestimated) was spent treating employees’ injuries every year.  There are other indirect costs – patient care suffers when nurses are unable to perform their jobs.  At least 2,400 nursing employees at the 153 hospitals operated by the VA suffer injuries every  year that interfere with their ability to work.

Says the VA, “In recent years, a patient body weight of 35 pounds was established as the maximum weight that providers can safely lift when lifting and moving patients without the risk of injury.  This limit requires a new approach to lifting and moving patients.”

To determine what that new approach should be, the VA looked at what was causing the injuries, and why.  (To see the cause-and-effect relationships leading to the nurse injuries at the VA in the Cause Mapping format, click on “Download PDF” above.)  As part of their routine tasks, nurses regularly lift more than 35 pounds.  (The weight of a 200-pound patient’s leg is about 40 pounds.)  Not only moving patients, but repositioning them was a problem.

The availability of equipment that provides lifting (or repositioning) assistance to nurses was a big issue.  Many hospitals purchase just a few pieces, which are frequently unavailable (or incredibly inconvenient) when needed.  The VA is working to install ceiling lifts in all patient rooms and everywhere else patients need to go (clinics, imaging departments, etc.).  They’re also using “floating” mattresses, which use an air stream to “float” patient mattresses from bed to gurney.

Even having readily available equipment didn’t completely solve the problem.  The VA is working to ensure that staff, who were accustomed to manually handling patients, would actually use the equipment.  Rather than minimal and occasional training, the VA trains on lifting constantly.  At least one employee on duty at all times is responsible for ensuring safe lifting technology is used.  Injuries that can be sustained from manual lifting are emphasized.  Additionally, each hospital has a “safety champion”.  This is a full-time position that ensures that other employees have what they need to ensure safe lifting and that the hospital as a whole puts in the time and money to protect worker’s backs.

These programs come at a cost, but appear to be very successful in reducing injury rates (and associated costs) at these hospitals.  The VA as a whole has spent more than $200 million since 2008 on its “safe patient handling program” and has reduced nursing injuries from moving patients 40%.  One California VA hospital has spent $2 million to install lifts across the hospital.  Before the program, it spent $1 million over four years hiring replacements for injured employees.  Last year, nobody got hurt badly enough to miss work.  Says Tony Hilton, the hospital’s safe patient handling and mobility coordinator (“safety champion”), “Remember, I’m your guardian angel.  You know I’ve got your back.”

Click on “Download PDF” to see an overview of the cause-and-effect relationships for which the VA is implementing solutions to reduce nursing injuries.  Or, click here to learn more about the VA’s program.