Category Archives: Root Cause

Root Cause

The Future Is Now?: Building a Neurobridge

By Kim Smiley

A chip was recently inserted into the brain of a man paralyzed from the chest down with the goal of allowing him to move his hand.  The tiny microchip is part of a system, called a Neurobridge, which uses a computer and a sleeve that fits around the patient’s arm in addition to the chip to allow the patient to communicate with his limb by bypassing his damaged spinal cord.  If the procedure works, the patient will be the first paralyzed person who has used his own thoughts to control a limb.  It will be a few weeks before the success of the procedure can be verified, but this is already an exciting development with the promise of amazing future applications of this type of technology.

So how does this Neurobridge work?  An article by The Washington Post “Ohio surgeons hope chip in man’s brain lets him control paralyzed hand with thoughts” by Jim Tankersley discussed the procedure in detail.  The patient’s brain was mapped prior to the surgery using a functional magnetic resonance imaging (MRI) machine.  The patient was shown pictures of hands moving and the areas of his brain that showed activity while he imagined moving his hand were recorded.  Once the surgery began, a portion of the patient’s skull was removed to allow access to his brain.  Electric pulses were fired into the area of the brain believed to control hand movement.  The patient was unable to move his hands, but did have movement of his upper arms so the team watched for a response in his upper arms to verify that the correct location was identified to insert the chip.

Once the chip was inserted into the brain, it was connected by wire to a transmitter port at the skull.  This transmitter port is connected by cable to a computer.  The signal from the brain then travels through the cable into the computer where it is run through an algorithm that mirrors the brainwaves that are present when a person is thinking about moving.  The signal now mimics brainwaves and is sent to a sleeve wrapped around the arm.  The sleeve has tiny electrodes that are used to stimulate the muscles to make the hand move.

It’s an ambitious project that if successful could help not only paralyzed patients, but others with limited motor function like stroke victims.   And as amazing as a Neurobridge sounds, it’s just one of many types of brain implants being actively researched and some of the ideas sound more like science fiction than plain old science.

The Neurobridge process can be illustrated by building a Process Map.  A Process Map visually shows the steps and is generally easier to read than the same information written in paragraph form.  To see a high level Process Map of this procedure, click on “Download” PDF above.

Root Cause

New Federal Rule Limits Level of Coal Dust Allowed

By Kim Smiley

On April 23, 2014, federal officials announced changes to the regulations governing dust-control practices in coal mines.  These changes are the most significant since the Coal Mine Health and Safety Act of 1969 and are intended to curb the increasing number of black lung cases.

Black lung is a potentially deadly disease that occurs when coal dust accumulates in a person’s lungs.  The coal dust slowly destroys parts of the lungs and blood vessels resulting in breathing problems, coughing and even death if the lungs are unable to adequately function.  As discussed in a previous blog, there is evidence that the number of black lung cases has been increasing in recent years.  Many believe that changes to the mining industry, such as modern high-speed mining equipment that produces high levels of dust and longer shifts, are increasing the risks to miners, in at least some mines.

The bad news is that there is no way to remove the dust once it has settled into the lungs and black lung disease is irreversible, but the good news is that it can be prevented by limiting the coal dust a person inhales and this is exactly what the new federal regulations are hoping to do.

The new regulations attempt to reduce the number of black lung cases by reducing the amount of coal dust exposure that is allowed during a shift by 25% (1.5 milligrams per cubic meter from 2.0).  Better monitoring of dust levels will also be required.  Miners regularly exposed to high levels of coal dust will be required to wear monitors that continuously track coal dust levels.  If dust levels are found to be above the limit, immediate actions to lower the dust limits will be required (such as slowing production) and respirators will be required to be available to miners working in the high dust areas.

The changes, first proposed in 2010, have been a long time coming and many in the mining industry have opposed them.  Some plan to continue fighting against the new regulations like Murray Energy Corp who have stated their intention to file a lawsuit against the U.S. Department of Labor saying the new rules are flawed, have no scientific support and are unachievable. As with any new regulation, only time will tell how smoothly the new changes can be implemented and how effective a solution they will be.

Root Cause

Concern Over Rising Costs of Specialty Drugs

By Kim Smiley

The good news is that more and more specialty drugs that show promise for treating serious medical conditions are becoming available.  The bad news is that some of these drugs are really expensive, both for insurance companies and individuals.

The new issues swirling around specialty drugs are illustrated well by the new drug for treating hepatitis C from Gilead Sciences.  The new drug is a significant improvement over previous treatment with a higher cure rate, a shorter duration and fewer reported side effects, but it carries an equally significant price tag.  The pills cost $1,000 each with a typical course of treatment costing $84,000.  The pills are in high demand and Gilead has reported a record breaking $2.3 billion in sales of their new hepatitis C drug during its first full quarter on the market.  But on the flip side, UnitedHealth Group, one of the largest US insurers, has reported it has spent $100 million to cover the hepatitis C drug and had their stock prices decrease.

An insurance company losing money may not seem like a source of concern, but more of the burden of the cost of specialty drugs is being passed along to patients as insurance companies figure out how to deal with the high price of specialty drugs.  Some insurance plans require patients to cover twenty percent of the cost of specialty drugs and 20 percent of $84,000 is beyond the means of many patients.  And some specialty drugs are even more expensive.  Also, financially healthy insurance companies are also vital if they are going to provide medical insurance at prices people can afford.

So why are these drugs so expensive? There are a number of factors that make specialty drugs so expensive.  One of them is that they generally treat a condition that relatively few people suffer from.  When more people take a particular drug, the development costs of the drug can be spread out and recouped over a larger population making the overall cost less for each individual.  The opposite occurs when there are fewer people who will take a particular medication: the development costs are more concentrated, making drugs for less common conditions more expensive in general.

There is also not usually a generic alternative available for specialty medication.  Many of the expensive specialty medications are newer and still protected by patents so that generics can’t be manufactured.  Most specialty medications are also biologics, meaning they are derived from living organizations, and they can’t be duplicated.  Medications with generic versions available tend to be chemically-based and easier to replicate.

Only time will tell how specialty medications will continue to shape the healthcare system, but their presence is only likely to grow as more drugs are developed.  Solutions will need to be developed to allow patients reasonable, affordable access to specialty medications, but also keep insurance and drug companies in business.

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

Root Cause

Lack of Available Treatment Leads to Fatal Heroin Overdose

By ThinkReliability Staff

The death of a young man in New Jersey on September 23, 2010 from a heroin overdose was tragic, but part of a trend becoming more and more common.  His death mirrors many of the other fatal heroin overdoses and by examining the issues that led to this fatality, solutions that could reduce the death rates from heroin overdoses across the country (and perhaps beyond) can be developed.

We will examine this particular case in depth by using a Cause Map, or visual root cause analysis. First we capture the particulars of the issue – what, when and where – as well as the impact to the goals.  The fatality is an impact to the patient safety goal, while insufficient help being available is captured as an important difference, and is also an impact to the patient services goal.

Beginning with an impacted goal (in this case, the patient safety goal), we ask why questions to determine the cause-and-effect relationships that led to the impact.  In this case, the death resulted from a heroin overdose.  Overdoses typically result from use of this specific drug, with which overdoses are not uncommon.  Though it is not clear if this played a role in this particular death, heroin overdoses can occur after a user attempts to get clean and relapses.  If the user goes back to the dose from before ending use of the drug, the body (if it has been drug free for some period of time) is unable to handle it, resulting in the overdose.

In order to overdose, heroin use has to begin.  The use of heroin is rapidly increasing, with an estimated 669,000 users by 2012.  First-time users increased from 90,000 in 2006 to 156,000 in 2012.  The reason for the increase is believed to be the comparatively inexpensive cost compared to prescription opiates.  While a gram of heroin might sell for $100, crackdowns against prescription drug “pill mills” have increased the cost of prescription opiates (like OxyContin) to $1,000 a gram.

Once heroin use has begun, quitting is extremely difficult.  While withdrawal symptoms are not life-threatening, they are extremely unpleasant (to use a massive understatement).  Because they are not life-threatening, emergency care is limited (the victim in this case was unable to be admitted to the hospital) and many insurance companies won’t cover treatment, which can be extremely expensive.  In 2012, only 2.5 million of the 23.1 million Americans who needed drug or alcohol treatment received aid at a special facility.

Hope for overdose victims is available in the form of naloxone.  Since 2001, the use of naloxone by emergency responders resulted in reversal of over 10,000 overdoses.  The Affordable Care Act should improve insurance coverage for treatment, though it may take years for this to be in effect and, with the treatment availability shortage, likely means that not everyone will get the help they need.

However, solutions that address the problem of heroin use itself are being developed.  According to Attorney General Eric Holder, “Confronting this crisis will require a combination of enforcement and treatment.  The Justice Department is committed to both.   Since 2011, the DEA has opened more than 4,500 investigations related to heroin.  And as a result of these aggressive enforcement efforts, the amount of heroin seized along America’s southwest border increased by more than 320 percent between 2008 and 2013.   Of course, enforcement alone won’t solve the problem.  That’s why we are enlisting a variety of partners – including doctors, educators, community leaders, and police officials – to increase our support for education, prevention, and treatment.”  With the help of the federal and local governments, as well as dedicated families of users, it is hoped that the tide of heroin use will be turned.  This will be the most effective way to stop overdose deaths.

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

Root Cause

Hundreds Affected in ‘Unprecedented’ Ebola Outbreak

By ThinkReliability Staff

The ongoing Ebola epidemic in Africa is “unprecedented” due to its high mortality rate (up to 90%), geographic spread (at least 5 countries have reported cases of the disease, which has spread to urban areas as well), and difficulty enforcing quarantines that would reduce the spread.  As with many outbreaks, the factors involved are complex and wide-ranging.

We can address the issues contributing to the outbreak by capturing them in a Cause Map, or visual root cause analysis. This intuitive method ties impacted goals to cause-and-effect relationships, allowing development of solutions to all aspects of an issue.

First we begin with the impacts to the goals.  The outbreak began in Guinea at some point in early 2014, but was reported to the World Health Organization (WHO) on March 23, 2014.  The outbreak is still ongoing and has impacted Guinea the most, but has also spread to neighboring countries.  The strain involved is the Zaire Ebola virus, which is spread by bodily fluids.

At the date of publication, the virus has killed at least 101 out of 157 infected in Guinea alone.  The infections and deaths, as well as the spread of the disease, can be considered impacts to the public safety goal.  This is the first outbreak to have impacted urban Guinea, though there have been dozens of outbreaks in Africa over the past 40 years.

“Why” questions are used to determine the cause-and-effect relationships that resulted in the impacted goals.  Death typically results from bleeding or shock, which occurs due to infection with the virus and insufficient treatment. Infection results from the initial transmission (caused by eating raw infected meat), and the spread of the disease.  The spread in this case has resulted from the unusual migratory pattern, both because of the easy and frequent travel between countries but also due to an as-yet-unknown factor.  Normal outbreaks involve a much smaller geographic area.) Victims are contagious for a long time, meaning the disease is easily spread, and it has been difficult to enforce quarantine, because of mistrust of local authorities and foreign aid workers.  According to Stéphane Hugonnet  of WHO, “The mortality rate is extremely important.  Nine out of ten patients will die.  If we look at this from the population’s perspective, why would you go to a hospital if you have almost zero chance of getting out of it.”  However, with effective care, there is a chance of surviving Ebola.

However, providing that care is another challenge.  There is no cure for Ebola, possibly because financial incentives to develop a cure for a rare disease that primarily strikes poor African villages isn’t there. Care essentially involves keeping a person alive long enough for their body to be able to fight back, difficult in a country that has 0.1 physicians for every 1,000 people fighting a disease that rapidly replicates and – through an unknown mechanism – disables the immune system.

So what’s being done to end this outbreak?  Medical teams from Doctors without Borders (or Médecins Sans Frontières) and WHO have been dispatched to the area.   These medical teams may include anthropologists, to better address local concerns regarding the disease.  WHO has also recommended limiting personal contact and a on raw bush meat.  Meanwhile, researchers are working on a vaccine to prevent  transmission of Ebola.  It is hoped that these steps together will end this outbreak – and prevent future outbreaks as well.

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

Root Cause

CDC Finds that 1 in 25 Patients Acquire an Infection While in the Hospital

By Kim Smiley

A recent headline from the New York Times reads “Infections at Hospitals Are Falling, CDC Says”.  That sounds like fantastic news right?  Well, what about this one from the same day from the Washington Post: “One in 25 patients has an infection acquired during hospital stay, CDC says.”  One in 25 doesn’t seem like great odds to me.  The two headlines give very different impressions of the problem, so which one is right?

The truth is that both statements are accurate, but neither tells the complete story.  To really understand the situation, you need to read a lot more than just the headlines. This is a good analogy for what happens in meetings every day.  Something goes wrong and everybody thinks they know what THE problem is or what is THE root cause.  Many times when people argue they aren’t really in disagreement, they are just focused on different parts of the same puzzle.

Building a Cause Map, a visual format for performing a root cause analysis, can help reduce miscommunication.  The first step in the Cause Mapping process is to fill in an Outline.  The top of the Outline lists the basic background information.  At the bottom of the Outline, there is space for listing the specific impacts to the overall goals.  People may argue about what THE problem is, but it’s hard to argue when specifically listing how the problem impacts goals.  For example, most people would agree that increased cost of healthcare is an impact to the overall economic goal of a hospital.  It may sound counterintuitive, but adding detail helps clarify the situation, when defining the problem and when actually determining what went wrong.

In the case of those headlines listed above, both refer to a recent study by the Center for Disease Control and Prevention that found that about 1 in 25 patients in US hospitals in 2011 acquired at least one infection based on data from 11,282 patients treated at 183 hospitals in 10 states.   (The total number of patients who acquired at least one infection is over 700,000.) The study estimated that around 75,000 of these patients died, but didn’t provide information on whether the deaths directly resulted from the infections.  The study also didn’t include nursing homes, emergency departments, rehabilitation hospitals and outpatient treatment centers.  Previous estimates put the number of infections each year at 2.1 million in the 1970s and 1.7 million from 1990 through 2002. The rate of infections also varies widely from hospital to hospital.  There is uncertainty in the data available, but the trend seems to be going in the right direction, even though the problem of hospital-acquired infections remains significant.  Before working to reduce the risk of a problem, it’s important to lay out all the facts and understand what exactly the problem is.  That generally requires more than a simple statement, which is why the Cause Mapping uses a formal Outline to define a problem.

After the Outline is completed, the next step is to analyze the issue by building a Cause Map by asking “why” questions starting with one of the impacted goals.  Hospital acquired infections are an impact to the patient safety goal so we could begin by asking “Why are patients getting infections in hospitals?”  This occurs because they are exposed to a pathogen.  Why?  There are pathogens at the hospital because many sick people are there for treatment.  Inadequate cleanliness also plays a role.  Additionally, the pathogen is able to infect the patient.  You would continue asking questions to determine why patients are being infected until you reach the desired level of detail.  Generally, the bigger the problem, the greater level of detail is needed.

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

Root Cause

US Doctors Issue Statement That Mothers Should Avoid Water Births

By Kim Smiley

The number of water births in the United States has been increasing in recent years and controversy over their safety continues to rage.  The latest development is that the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recently issued a joint statement saying that water births are not recommended and should be avoided, but some midwives and mothers disagree and adamantly defend the benefits of birthing in water.  The doctors agree that soaking in water during early labor may make the experience more pleasant for mothers, but feel that actual birth should be outside of the birthing tub.

One of the issues is that the benefits of water birthing are difficult to prove and the potential risks are difficult to quantify .  Some mothers believe that birthing in water helps relieve pain and can aid in a drug-free delivery.  Supporters of the practice also think that birthing in water can shorten labors, which reduces stress on the mother and the baby.  Some midwives have also expressed a belief that water births are gentler on babies, saying that many do not cry when they are born.  It’s difficult to definitively study the impacts of water births because birth outcomes depend on so many factors and you can’t do a double-blind study because it’s pretty much impossible to have a placebo for a water birth.

There have been reports of individual cases where something went wrong during a water birth, but there is little information on how often this occurs.  There is general agreement that complications are rare, but the doctors  releasing the statement feel the risk of complications outweighs the benefits.  The most serious concern is the baby drawing its first breath underwater, which could lead to breathing issues and even drowning.  There is also a risk of umbilical cord ruptures since the baby must be brought to the surface relatively quickly and the cord may be too short.  There is also increased risk of infection for the mother and baby since they are both exposed to potentially contaminated water because birth can get messy.

Until now, there has been little formal guidance provided about water births.  Providing more information for expectant mothers is a great first step, but disagreement between medical professionals about birthing methods can add confusion to an already stressful time.  Until more studies are done to provide a better understanding of the risks involved, women will have to rely on their own judgment and the guidance of their healthcare provider.

To view an Outline and Cause Map of this issue, please click “Download PDF” above.

Root Cause

New Studies Shed Light on Statin Side Effect Concerns

By Kim Smiley

Usage surveys have found that the majority of people prescribed statins in the United States discontinue using them within a year. The number one reason stated by patients for stopping statin use is concern with side effects.

This issue can be analyzed by building a Cause Map, a visual method for performing a root cause analysis.  The first step in the Cause Mapping process is to define the problem by filling an Outline with the basic background information (who, what, when, where, etc.).  Additionally, the Outline is used to capture how the problem impacts the goals so that the magnitude of the problem is well understood.   Once the Outline is complete, the analysis is done by building a Cause Map by asking “why” questions to find the causes that contribute to an issue.

For this example, the fact that patients aren’t taking prescribed statins is an impact to the patient goal.  This occurs because patients were prescribed statins and they are not using them.  Looking at each cause individually, let’s first ask why patients were prescribed statins.  A physician wrote a prescription for statins because the patient was considered at risk for heart disease and statins can reduce the risk of heart disease.  Statins have been shown to reduce cholesterol levels in the blood and high cholesterol can lead to blocked arties that can contribute to heart disease.  Cholesterol is reduced because statins inhibit an enzyme in the liver that controls cholesterol production in the body and the majority of cholesterol is produced by the liver.

So the question that still needs to be answered is why aren’t patients taking their statins if they can reduce their risk of heart disease?  The most significant reason that patients are discontinuing statin use is because they are concerned about side effects and the concerns haven’t been adequately addressed. Patients are concerned about side effects because they believe they have experienced side effects or they are generally worried about potential side effects.

Like most other medications, statins can have serious side effects, such as liver injury, cognitive impairment and potential for muscle damage (especially when combined with certain other medications.  According to the U.S. Food and Drug Administration, the value of statins in preventing heart disease has clearly been established and the benefits outweigh the risks, but one of the reasons that patients are concerned about side effects is that there are very outspoken critics of statins that do not agree with this assessment.  For the purpose of this example, we will assume that the FDA is correct that patients would benefit from taking statins if they are prescribed and that it is in fact a problem if patients discontinue using stating when their physicians have recommended them.

The final step in the Cause Mapping process is to come up with solutions that can be implemented to help reduce the risk of a problem occurring in the future. So how can the risk that patients will discontinue statins be reduced?  One possible solution would be to give patients reliable information that shows that statins are relatively safe and are effective at reducing the risk heart disease.  If patients believe that the benefits of statins outweigh the risks, they will be significantly more likely to take them.  More information is becoming available as researchers continue to study the benefits of statins and the frequency and severity of side effects.  For example, a recent study that used 83,000 patients and randomized statin therapy and a placebo found that “only a small minority of symptoms reported on statins are genuinely due to the statins: almost all would occur just as frequently on placebo”.  With more data about the effectiveness of statins and the accurate information the risks associated with them patients can make decisions based on real data and better determine if they should keep taking the statins.

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

Root Cause

13-Inch Surgical Tool Left In Patient for Months

By Kim Smiley

For about two months after surgery to remove a large malignant tumor Donald Church complained of severe pain.  Initially, he was told that it was normal pain associated with recovery from a major surgery, but an x-ray was ordered after his physician felt a lump in his abdomen.  The x-ray revealed that a malleable retractor similar in size to a ruler had been left inside his body after surgery.  A second surgery was done to remove the tool.  Mr. Church is not expected to suffer long-term health consequences and received a $97,000 settlement.

A Cause Map, a visual format for performing a root cause analysis, can be built to help understand how this issue happened.  Once all the causes that contributed to an issue are found, potential solutions can be found and the most promising can be implemented to help reduce the risk of a similar issue reccurring.

So how did this happen?  How does a large surgical tool get left inside a patient?  This occurred because the patient needed surgery to remove a tumor, the malleable retractor was used during the surgery and the surgeons were unaware that the tool remained inside the patient. (These causes are vertical on the Cause Map with “and” between them because all 3 were necessary for the issue to happen.)  A malleable retractor was used while the wound was being closed to help protect the organs under the wound from possible puncture from the suturing needle.

The surgeon was unaware that the tool was inside the patient because he couldn’t see it and there wasn’t an adequate system in place to manage surgical tools.  Malleable retractors are normally held partly out of the wound, but it had slipped entirely inside the wound during the surgery.  Once the tool was out of sight, it was forgotten.  While many hospitals have requirements to formally count surgical tools as they enter and leave the operating room to ensure that all are accounted for, there wasn’t a policy in place in the facility that performed the surgery at the time.  With no formal system to track tools, there weren’t any easy indications to the operating team that there was a problem.

While this is a particularly egregious example, there are an estimated 4,000 cases of retained surgical items each year in the United States. Better solutions need to be found to reduce the risk of this preventable and potentially deadly problem from happening.  A simple solution to reduce the risk for retained surgical items is to institute a formal procedure for counting surgical supplies and tools before and after surgery.  Simple manual counts are a first step, but errors still occur, especially in the often hectic and stressful environment in an operating room.  Some hospitals use a visual inventory system where tools are brought in a special storage bag with an individual compartment for each item.  As items are done being used they are put back into their specific spot.  If all compartments are full, everything is accounted for so it’s easy to tell if something is missing.

Another solution that is gaining in popularity is use of an electronic tracking system.  The most common use of electronic systems is to track sponges, which are by far the most common object left inside patients.  Each sponge has an electronic tag and the patient is scanned after surgery to verify that none were left behind.  Sponge tracking systems add about $8 to $12 to the cost of each surgery and have dramatically reduced the number of retained sponges when used.

To view a high level Cause Map, click on “Download PDF” above.

Root Cause

New Study Finds that Dirty Stethoscopes May Spread Germs

By Kim Smiley

It’s been well documented that washing hands can prevent infections and in the same vein some researchers are now asking questions about potential contamination risks posed by stethoscopes and other small medical equipment used to examine multiple patients. In a recent study, stethoscopes were tested after they were used to examine patients and most were found to have bacteria on them.  Unlike the guidance provided for hand washing, there are currently no guidelines that require physicians to disinfect their stethoscopes between patients.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  In a Cause Map, the causes that contribute to an issue are laid out to show the cause-and-effect relationships to aid in understanding the role the causes played.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information for a problem such as the location and time it occurred.  Additionally, how the issue impacted the organizational goals is documented on the Outline.  The possibility of patient exposure to bacteria is an impact to the safety goal in this example.  Once the impact to the organizational goals is defined, the Cause Map is built by asking “why” questions.

Why is there a risk of patient exposure to bacteria?  This is happening because a contaminated stethoscope may be placed on a patient’s skin.  Stethoscopes are commonly used to listen to a patient’s heart and lungs and they work best when placed directly onto the skin.  Stethoscopes may get contaminated from being used on a person with bacteria on their skin and stethoscopes are not necessarily cleaned between uses.  Stethoscopes aren’t always cleaned between uses because there are currently no guidelines requiring it.  There aren’t any guidelines because it hasn’t been clear if they are needed.  There has been limited research done to understand the issue and determine how much of a risk of illness a contaminated stethoscope may pose, especially if used on healthy skin.

The new study is a good early step in understanding the issue, but it was a relatively small study and a larger scale study may be needed in the future.  The study “Contamination of Stethoscopes and Physicians’ Hands after a Physical Examination” looked at the stethoscopes used by three physicians as they examined a total of 83 patients in a Swiss hospital.  The researchers found bacteria on the stethoscope after 71 of the patient examinations.  It’s also difficult to determine whether bacteria on stethoscopes is responsible for spreading bacteria and whether it has actually caused illness.

The final step in the Cause Mapping process is to come up with solutions that can reduce the risk of the problem recurring in the future.  One good thing about this particular issue is that the solutions are relatively easy and cheap.  Physicians who are concerned about the cleanliness of their stethoscopes can either give them a give clean with disinfectant between patients or use disposable covers that are already commercially available.  Guidelines about cleaning stethoscopes are likely years in the future, but you can always ask your physician about the issue or to clean the stethoscope if you are concerned.