Root Cause

Concern about Quality of Medical Care for Inmates

By ThinkReliability Staff

Those in the custody of law enforcement are almost completely dependent upon law enforcement for their basic needs.  One of these needs that is not always being met involves proper medical care, or even checks after the declaration of a medical emergency.   Per Dr. Ronald Shansky, a physician who performs court-ordered monitoring of inmate conditions for Milwaukee County, Wisconsin, failure to provide proper medical care is a failure to uphold constitutional obligations to those in custody.  After all, he says, “The inmate is completely dependent.  Unless the system creates the opportunity for the medical tests to be done, the medications to be provided, it’s not going to happen.”

In Milwaukee County, which was the subject of a recent investigative report by the Milwaukee Journal Sentinel, 18 people died in the custody of law enforcement in the county between 2008 and 2012.  Of these deaths, 10 were found to be related to improperly treated or monitored conditions.  By performing a detailed investigation of just one of these deaths, solutions that could reduce the risk of all custodial deaths due to improperly treated or monitored conditions can be incorporated.

We can perform this investigation by creating a Cause Map, or visual root cause analysis.  We begin with the specifics of one of the 10 cases of custodial death.  For this example, we’ll look at the death of Jeremy Cunningham.  Mr. Cunningham died the morning of June 22, 2011, while he was being held at the Milwaukee Secure Detention Facility for violation of parole.  Two important factors to note were that the inmate reported that he had alcohol and drugs in his system (taken within 8 hours) and that the inmate had a heart condition.

Next we determine the impact to the goals from the perspective of the Department of Corrections.  The inmate safety is impacted due to the death of a person in custody. Because of the constitutional obligation of law enforcement to care for those within their custody, the compliance goal is impacted.  Additionally, due to the insufficient treatment of the victim while in custody, the inmate services goal was impacted.

Beginning with the inmate safety goal, we can ask why questions to determine the causes of the impact to the goal.  The patient died because of a health issue that was not sufficiently treated.  Though the autopsy determined that the inmate died from cocaine poisoning, a pathologist who reviewed the results believes that alcohol withdrawal is more likely.  Because the cause of death is still under debate, we can use a “?” to indicate that it is not yet known (and more evidence is needed to determine the actual cause of death, though this is unlikely to occur).

Had the patient experienced the health issue but received treatment, he would have been less likely to die as a result.  Thus, the insufficient treatment from the prison staff is a cause of his death.  From available information, several opportunities were missed to assess the inmate’s health needs.  In other cases involving inmate deaths, an expectation of 30-minute check of prisoners is discussed, though it appears that requirement is not frequently being met.  This is likely because of chronic understaffing due to funding issues.  Even after the inmate’s roommate pressed the emergency call button when the inmate begin seizuring, nobody was sent to check on the condition of the inmate. (The emergency call button was pressed during the night, and the inmate was found dead in the morning.)  At the time of the death, there was no policy in place specifying what to do upon receipt of an emergency call, though the alcohol withdrawal instructions state that an ambulance should be called if an inmate experiences seizures.

Although the inmate had reported use of alcohol and cocaine within 8 hours before his incarceration, he was not monitored for withdrawal symptoms, although nurses had indicated monitoring was necessary.  Additionally, the prisoner did not receive any special care or instructions due to his heart condition.  It’s possible his heart condition wasn’t known – he died within 20 hours of entering the facility, which does not have an on-site medical practitioner, and prison medical records are delivered within 24-48 hours.

The failure of the system to provide adequate care to this inmate, as well as the 9 others who died in custody due to failure of monitoring or treatment has led to some changes being adopted by the Department of Corrections.  (Other changes are being forced by the legal system.)  These include posting notices on the doors of inmates who need extra attention, analyzing blood alcohol content upon arrival, and requiring an in-person evaluation to   respond to all emergency calls from within the prison. Hopefully these changes will reduce the failures that led to Mr. Cunningham’s death as well as some of the other deaths.

To view the investigation of Mr. Cunningham’s death, as well as a timeline outlining all 18 deaths in Milwaukee County law enforcement custody, please click “Download PDF” above.  Or click here to read more.

Root Cause

Norovirus Outbreak on Cruise Ship Sickens Over 600

By Kim Smiley 

A cruise ship has once again made national headlines for a negative reason.  A norovirus outbreak on Royal Caribbean’s Explorer of the Seas sickened nearly 700 hundred people during a cruise that ended on January 29, 2014.  Noroviruses are extremely unpleasant and cause extreme stomach cramps, vomiting and diarrhea, not exactly the stuff fantastic vacation memories are made of.  According to the Centers for Disease Control and Prevention (CDC) there have been 56 gastrointestinal outbreaks on cruise ships in the past five years, but this outbreak is notable because it was one of the largest in 20 years.

This incident can be analyzed by building a Cause Map, a visual format for performing a root cause analysis that intuitively shows the cause-and-effect relationships between the causes that contribute to an issue.  A Cause Map is built by asking “why” questions and documenting the answers. ( To view a high level Cause Map of this example, click on “Download PDF”.)

In this example, the initial source of the norovirus is not known and may not be able to be determined, but a Cause Map can still be helpful in understanding how the outbreak spread and how the outbreak impacts the goals of the company.  The CDC did investigate the outbreak, but it can be difficult to determine how the norovirus was brought onboard.   Noroviruses are common, especially during the January through April peak season for norovirus infections, and cruise ships need to have a plan to deal with sick passengers because simply preventing a norovirus from coming onboard isn’t realistic.

Once a person infected with a norovirus is onboard a cruise ship, the illness can spread quickly because is highly contagious.  Noroviruses can be transmitted by contact with an infected person, consuming contaminated food and even touching contaminated surfaces such as stair handrails.  Cruise ships, along with other confined spaces such as nursing homes, are particularly susceptible to fast spreading outbreaks of norovirus because there is a large number of people in a small space and it can be a challenge to isolate sick people.  Many cruise ships also serve meals buffet style which can pass the virus quickly to a large number of people.

The cruise ship did have a plan in place to help mitigate any outbreaks and the number of ill passengers was decreasing by the time the ship returned to port.  Sick passengers were isolated to their cabins and crew increased cleaning and sanitation of the ship during the cruise.  The ship was also given an especially thorough cleaning and extra sanitizing prior to departure of the next cruise.  In order to track and help cruise ships prevent outbreaks the CDC also runs a Vessel Sanitation Program, which monitors illness at sea and provides information about disease prevention.  If plan to take a cruise, the best way you can protect yourself is by frequently and thoroughly washing your hands with soap and water.

Visit our previous blogs if you are interested in learning more about other cruise ship examples:

Engine Room Fire Results in Cruise Ship Nightmare

Cruise Ship Loses Power

The Salvage Process of Costa Concordia

Root Cause

Man Found Dead After Waiting 8 Hours for Emergency Treatment

By ThinkReliability Staff

A man seeking treatment for a rash at a Bronx hospital emergency room (ER) was found dead eight hours later, still in the waiting room, of as-yet unknown cause.  The incident is currently under investigation by the New York State Department of Health and the cause of death will be determined by a medical examiner.

When performing an investigation of a case like this one, it’s important to focus on the goals that were impacted by the incident and determine all the causes that resulted in the goals being impacted, not just finding one “root” cause.  In this case, the impact to the patient safety goal has clearly been impacted because of the death of a patient within the hospital itself waiting to be seen.  The patient service goal was clearly impacted because the patient did not see a doctor in the six hours – or more – between arrival and his death.  The schedule goal is impacted by the significantly higher-than-average wait at this particular ER.  Lastly, the labor goal appears to be impacted by insufficient staffing levels.

According to the hospital, the cause of the patient’s death is simple.  Per the Hospital spokesperson: “His name was called several times on several occasions, and he did not respond… People have personal responsibility when your name is called, you have to get up and see the doctor.”  The hospital says that all guidelines were met and, even goes so far to add that “probably this scenario in this shape and form has happened in any big hospital in New York City.”

Many don’t find that answer acceptable. Although hospital guidelines may have been followed, there’s no discussion of whether the guidelines were adequate.  It is apparent that the hospital guidelines do not include any sort of care or supervisor for patients prior to being called in to the waiting room.  However, there’s no discussion of whether that meets the standard of care expected of these hospitals.  As this lack of oversight resulted in the death of a patient going unnoticed – potentially for hours – in a hospital waiting room.

In addition, the incident has brought up questions about the impact of the long wait time.  The wait at the emergency room for this hospital is an average of 306 minutes – more than 5 hours.  The national average is 137 minutes and the average in the state of New York is 155 minutes.  When the patient was called, starting at 2 and a half hours after entry, he may have well been asleep, given that the next interaction he had was with a security guard who woke everyone in the waiting room at 2 a.m.  This periodic waking of people in the waiting room – meant to ensure that nobody was using the waiting room as a shelter – next happened at 6:40 AM, and is when the patient was found dead.  Unofficial reports suggest the patient may have been dead for hours.  The patient was last seen moving at 3:45 AM on security cameras.

These questions demonstrate the fallacy of the one “root” cause approach.  The hospital’s assessment begins – and ends – with placing blame on the patient for not responding to a call in the ER.  But this expectation may not be appropriate in all cases.  Although a shorter ER wait time may or may not have saved the life of the patient in this case, it would certainly ease the strain of an ER visit for most patients and potentially save a life.  There have been several publicized cases of deaths or significant disabilities resulting from waiting too long in the ER.  Certainly an incident like this occurring at a hospital merits a review of policies that allowed a man to die unnoticed by staff.

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

Root Cause

Inappropriate Antibiotic Risk Not Decreasing for Adults

by ThinkReliability Staff

Infections caused by bacteria (such as sinusitis and tonsillitis) respond to antibiotics; those caused by viruses (such as bronchitis and influenza) do not.  Prescribing antibiotics for viral infections will not treat the infection and contributes to the rise of antibiotic-resistant bacteria. This is known as inappropriate antibiotic use.   A recent study showed that efforts to reduce inappropriate antibiotic use have been effective in pediatric, but not adult, patients with acute respiratory tract infections.

To thoroughly understand the issue, we consider both the effects and causes of inappropriate antibiotic use.  A cause-and-effect diagram, or Cause Map, visually lays out these cause-and-effect relationships.

The effects of the issue are captured in a problem outline.  Effects are captured with respect to an organization’s goals.  In this case, the impacted goals are wide-ranging, so we look at them from a general health industry perspective.  Unnecessary antibiotic use can impact the person to whom they are prescribed, which impacts the patient safety goal. Unnecessary antibiotic use also increases antibiotic resistance, a growing public health problem with no easy answers.  This can be considered an impact to the public safety goal.  (For more information, please see our previous blog about antibiotic resistant bacteria and fungus.)

Besides patient and public health safety concerns, unnecessary use of antibiotics can result in unnecessary cost.  A program at a University of Maryland hospital that monitored antibiotic use resulted in $3 million in annual savings with no impact to care quality.  However, when the program ended, so did the savings.

In addition to capturing the impact to the goals in the problem outline, we can capture general information about the issue being analyzed, including important differences.  These differences can provide valuable information about potential causes to be evaluated.  An interesting difference noted in the study is that efforts to reduce unnecessary antibiotic use were effective for pediatric patients but not adults.  So far, the reason for the difference in pediatric and adult use has not been determined, but a decrease in inappropriate antibiotic use for children is a positive step forward.  (And not just because of antibiotic resistance.  A 2012 study found that antibiotic use in infants can lead to obesity.  Click here to learn more.)

After the effects of an issue are determined, cause-and-effect relationships that will lead to the causes of an issue can be developed by asking “why” questions.  In this case, several possible causes for inappropriate antibiotic use have been suggested.  Identifying causes allows more opportunities for solutions to address these causes.

Perceived pressure from patients to receive an antibiotic when presenting to the emergency room for an acute respiratory infection and difficulty making a definitive diagnosis to determine whether the infection is viral or bacterial are two of the reasons given for the continued inappropriate use of antibiotics.  Patient education can help.  A review of 89 studies in 19 countries found that prescriber access to education and advice or restrictions on prescribing antibiotics have been effective in reducing inappropriate antibiotic use.

A surprising increase in the use of antibiotics appears to be due to a reduced out-of-pocket cost borne by patients.  After Medicare Part D went into effect, reducing drug costs for some patients, a study found increases in antibiotic use for acute respiratory infections.  The study suggested that changes in patient cost-sharing may be effective in reducing unnecessary antibiotic use.

It’s likely that a combination of causes will be needed in order to reduce the prescribing of unnecessary antibiotics to a minimal level that can aid in the fight against antibiotic resistance.  Ideally, further studies will be able to develop lessons learned from the successful pediatric programs that have reduced inappropriate antibiotic use so they can be implemented for adult patients as well.

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

Root Cause

The Willie King Case: Wrong Foot Amputated

By Kim Smiley

In one of the most notorious medical error examples in US history, the wrong foot was amputated on a patient named Willie King on February 20, 1995.  Both the hospital and surgeon involved paid hefty fines and the media had a feeding frenzy covering the dramatic and alarming mistake.

So how did a doctor remove the wrong foot?  Such a mistake seems difficult to comprehend, but was it really as mind boggling as it looks at first glance?

The bottom line is that the doctor honestly believed he was removing the correct foot when he began the surgery. The blackboard in the operating room and the operating room schedule all listed the wrong foot because the scheduler had accidentally listed the wrong foot.  After reading the incorrect paperwork, the nurse prepped the wrong foot.  When the doctor entered the operating room, the wrong foot was prepped and the most obvious documentation listed the wrong foot.  Basically, the stage was set for a medical error to occur.

The foot itself also looked the part.  The patient was suffering from complications of diabetes and both of his feet were in bad shape.  The “good” foot that was incorrectly removed looked like a candidate for amputation so there were no obvious visual clues it wasn’t the intended surgery site. Other doctors had testified in defense of the doctor saying the majority of other surgeons would have made the same mistake given the same set of circumstances.

There was some paperwork that listed the correct foot to be amputated, such as patient’s consent form and medical history.  This paperwork was available in the operating room, but no procedures in place at the time required the doctor to check these forms and these forms were far less visual than the documents where the incorrect information was listed.  Additionally, the doctor never spoke directly with the patient prior to the surgery which was another missed opportunity for the mistake to be caught.

Clearly the procedures needed to be changed to prevent future wrong site surgeries from occurring and a number of changes have been incorporated in the time since this case occurred to help reduce the risk of this type of medical error.  Surgeons in Florida are now required to take a timeout prior to beginning a surgery.  During the time out they are required to confirm that they have the right patient, right procedure and right surgical site.  This rule has been in place since 2004.

Mistakes will always happen, such as numbers being transposed or misheard words over the phone, but small mistakes need to be caught before they become big problems. Procedures like a timeout can significantly reduce the likelihood of an error going uncorrected.  In an ideal world, the simple mistake by the scheduler would have been caught long before it culminated in a surgery on the wrong body part.

A visual root cause analysis, called a Cause Map, can be built to illustrate the facts of this case.  A Cause Map intuitively lays out the cause-and-effect relationships including all the causes that contributed to an issue.  To view a Cause Map of this example, click on “Download PDF” above.

Root Cause

Patient Dumping Has Dangerous Results

By ThinkReliability Staff

“Patient dumping”, when hospital patients are improperly discharged, sometimes to dangerous areas, or even out of state, and sometimes without proper instructions for care, is a serious risk to patient safety and health and can result in serious costs for the hospitals and people involved.  In a recent case, a California hospital made a settlement for $250,000 in civil penalties and legal fees for leaving a patient at skid row without making any arrangements for her.

This case – and others like it – lead to obvious concerns for the health and safety of these patients.  That’s led city attorneys and homeless advocates to crack down.  Operators of homeless shelters and rescue missions in the area have installed “dump cams”, which allow them to identify cases where patients are being “dumped”.  In Los Angeles, the police department has stated they will arrest anyone who leaves patients outside a shelter.  And Mike Feuer, a city attorney, says, “Patient dumping is intolerable to me. I do have it in my mind to send a message to other hospitals that this won’t be tolerated.”

Although patient dumping appears to have lessened in recent years, it’s still a real problem.  In other newsworthy cases, another Los Angeles hospital settled a group of charges in 2011 when it discharged a disoriented patient – still in her hospital gown – by taxi and she was left in the street.  Yet another area hospital was sued for negligence in 2012 when it left a patient being treated for schizophrenia outside a rehabilitation center without notifying the patient’s family.  In 2013, the city of San Francisco filed suit against the state of Nevada, saying that a psychiatric hospital had issued bus tickets to California cities for mentally ill patients without making arrangements for them.

Even though the risks to patients are apparent (and financial costs to hospitals are possible), these problems continue to occur.  In cases where organizations don’t seem successful at ensuring the safety of its patients (or employees), the government will step in.  In this case, Los Angeles in particular has implemented a “patient safety zone” which encompasses most of the city’s downtown, where it is illegal to leave patients unless they are in the care of a family member.  Additionally, hospitals must obtain written consent from patients to take them to a place other than their home.

This of course can be tricky when dealing with homeless, mentally ill, or patients without relatives living nearby.  Although patient resources when dealing with these cases are limited – making proper discharge difficult in some cases – leaving a patient alone in an unfamiliar, dangerous area is never the right answer.

The impacted goals resulting from patient dumping, some potential causes, and the solutions that have been implemented by the city of Los Angeles are shown in a Cause Map, or visual root cause analysis.  To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

27 Patients to be Tested After Ultrasound Probe Sterilization Error

By ThinkReliability Staff

On December 21, 2013, 27 men were notified that, due to improper sterilization of equipment used for their prostate procedures, they should be tested for HIV and hepatitis B and C.   Both the medical center and patients involved are understandably concerned about how they got to this point.

In order to better understand the issues involved, we can put together an investigation file using Cause Mapping, a visual form of root cause analysis.  First, we capture the basic information about the issue.

The procedures were performed from September 19 to December 10 of this year at a Seattle medical center and involved ultrasound probes used for prostate procedures.  Because more than one date is involved, we can use a timeline to add more detail to the investigation.  In this case, patients were found to have been affected beginning September 19 and ending December 10, though it’s not clear if the incorrect sterilization began on that date, or if that was the first date that a probe was used on a patient with a communicable disease.  The improper sterilization was reported to hospital officials December 17 and affected patients were notified beginning December 21st.  As a result of information released by the medical center, we know that one step in the sterilization process for the probes was not completed.  We capture this as an important “difference” that may aid in the analysis.

Next, we determine the goals that were impacted as a result of the issue.

The patient safety and patient services goals were impacted due to the risk of disease transmission for the 27 patients (the probability of which is estimated to be very low).  The compliance goal is impacted because of equipment that was not sterilized as required.  The labor goal is impacted because the medical center is paying for two rounds of HIV and hepatitis testing for the affected patients.  If it is determined over the course of the investigation that other goals were impacted as well, these can be captured in the Problem Outline as well.

Once we have determined the impacted goals, we use these goals as the first “effect” to determine the cause-and-effect relationships that resulted in the issue.  In this case, the patient safety and services goals were impacted due to the risk of disease.  The disease risk resulted from the reuse of prostate probes that had the possibility to spread disease.  The disease risk occurred because the probes may have been used on a patient that had a communicable disease and the probes were not properly sterilized before their reuse.

We can show the steps that should have occurred in the sterilization process of these probes, as well as where the specific issue in the process occurred, in a Process Map.  This map shows the steps involved in a procedure, in this case the ultrasound probe sterilization procedure.  After a probe is used, it goes through a three-step process, involving cleaning, disinfecting or decontaminating with a disinfectant spray, then sterilization by being doused with sterilization fluid.  Then the sterilized equipment is placed in a protective sheath before re-use.  (Because of the use of this protective sheath, the probe, when properly used, does not contact the patient, decreasing the risk of disease transmission.)  In this case, the sterilization step was not performed.

We include the fact that the procedure was not performed properly in the Cause Map.  The Chief Medical Officer reports that their investigation found that the cause was “human error” and no more information has been released.

In order to determine effective solutions to prevent the issue from recurring, more detail needs to be obtained about the expectations for the process being performed, as well as the verification (if any) that took place to ensure that the procedure was being performed correctly.  Once it’s possible to determine what allowed the process to break down, safeguards that will reduce the risk of it happening again can be implemented.

To view the initial investigation file, including the Outline, Cause Map, Timeline and Process Map, please click “Download PDF” above.

Root Cause

FDA Ruling Questions Safety and Effectiveness of Antibacterial Soaps

By Kim Smiley

The Federal Drug Agency (FDA) has formally questioned the safety and effectiveness of antibacterial soaps with a ruling on December 16, 2013.   Manufacturers of antibacterial soaps have one year to provide data that proves that anti-bacterial soaps are both safe and more effective than regular soap and water. Any antibacterial products that have not provided sufficient data to satisfy regulators by late 2016 would have to be reformulated, relabeled or removed from the market.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map visually lays out the many causes that contribute to an incident to intuitively show the cause-and-effect relationships.  When starting the Cause Mapping process, the first step is to fill in an Outline. The Outline documents the basic background information as well as lists how the issue impacts the goals.

In this example, there are a number of impacts to the goals worth considering.  The potential financial impacts are certainly significant.   It is estimated that it will cost companies between $112 million and $368 million to comply with the new regulations.  The safety goal is also a key component of this issue since safety concerns are one of the driving factors for the new push for additional data.

The FDA is concerned about the safety of antibacterial soaps because many contain triclosan and other similar chemicals.  Studies using lab animals have found that triclosan can disrupt hormones, such as sex hormones and thyroid hormones.  Interference with the body’s natural hormone levels can have a huge impact on how the body functions, especially in children who are still growing.  Use of antibacterial agents has also been associated with an increase in allergies, although more data would be needed before a definitive link could be established.  Use of antibacterial products may also lead to increased resistance to antibiotics which is an issue generating increasing concern.

In addition to questions about safety, there are also questions about the effectiveness of the products.  Microbiologists at the FDA have stated that there is currently no evidence that use of over-the-counter antibacterial soap is any more effective at illness prevention than simply washing with soap and water.  Consumers buying the products assume that they are getting some sort of additional protection against illness, but that doesn’t appear to be the case.  It is also worth noting that viruses are the most common cause of infection in the United States and antibacterial products are powerless against them.

The bottom line appears to be that antibacterial soaps are more expensive, have potential risks associated with them and aren’t better at preventing illness.   Manufacturers will have the opportunities to present data about their products to the FDA, but I expect that there will be some significant changes to antibacterial products in the future.

The current ruling does not apply to hand sanitizers which are typically alcohol based so don’t be afraid of using sanitizer if hand washing is unavailable.  Also, studies have proven triclosan is effective at fighting gingivitis in toothpaste.  This current ruling only applies to personal hygiene products (like hand soap), but I suspect this is just the first of many hard questions for the billion dollar anti-bacterial product industry.

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

Root Cause

Patient Gets MRI (and a Diagnosis) Only After 24 Visits to 13 Doctors

By ThinkReliability Staff

In a tragic case of incorrect diagnosis, a 16-year-old patient died January 24, 2013, eleven months after being diagnosed with “migraines”.  In fact, the patient had a rare brain tumor (known as a disseminated oligodendroglioma-like leptomeningeal tumor).  She died eight days after receiving an MRI that finally properly diagnosed the causes of her headaches, numbness, nausea and eyesight problems.

It’s unclear if earlier diagnosis would have saved the life of the patient.  Though the prognosis is poor for a leptomeningeal tumor, a oligodendroglioma that is treated before it is disseminated gives a long-term survival chance to 80-100%.  The tumor had disseminated once it was found on the MRI, eleven months after the patient was diagnosed with migraines.  However, even if her prognosis was poor, the patient could have spent the last eleven months of her short life enjoying time with her family and friends, instead of making 24 trips to 13 different doctors and, in one particularly devastating appointment, being accused of “putting the symptoms on”.

Although the coroner at the inquest said there was no need to make a formal recommendation for changes at the hospital that failed to diagnose the patient, a spokesperson for that hospital said “In the next few weeks, many of the clinicians who looked after Natasha will be meeting to discuss this sad case and ensure that any opportunities for learning are not missed.”

It is hoped that these opportunities for learning can reduce the possibility of another patient suffering as this patient did, due to a misdiagnosis.  Misdiagnosis is a common source of medical error.  According to an article by Michael Astion, MD, PhD, “Available data suggests that misdiagnoses occur in 15% or more of clinical cases, but overall there is very limited data on the frequency of misdiagnosis in medicine.”  Especially in rare clinical cases such as this one, sharing details of the disease and diagnosis may help other clinicians in the same position.

In order to effectively determine lessons learned and improvements that can be made, the details of a case need to be presented clearly and concisely.  I’ve put together the details of the case in a Cause Map, which uses cause-and-effect to demonstrate the linkage of the issues that led to the tragedy discussed here.

In a blog discussing the cases and possible responses, Suzanne Leigh suggests that if an MRI was denied, other cheaper alternatives, such as a CT scan, be considered.  She also suggests a much more thorough review to “ensure that in the future, scans are  not withheld from patients with potentially life-threatening conditions”  and that the hospital involved should “study the flaws in the system and human errors that led to the failure of 13 doctors to order a diagnostic MRI that would have resulted in emergency treatment earlier in the disease’s progression”.  Given the tragedy of this case, the suggestions seem far more appropriate than the treatment of the patient over the last year of her life.

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

Root Cause

Baby Suffers Brain Damage After Delay in Newborn Testing Results

By ThinkReliability Staff

A recent watchdog report by the Milwaukee Journal Sentinel found that 3.9% of screenings from a particular hospital took 5 days or longer to reach the lab, though the state guidelines are 24 hours.  (Statewide, 2.9% of samples take five days or more.)   This typically occurs because of a practice called “batching”, where multiple samples are saved to send in as a group.  Although the practice of batching is not recommended, and the state guidelines warn “DO NOT BATCH SPECIMENS”, there are no laws requiring hospitals to send in samples within the 24 hours, nor are there are penalties for not doing so.  According to the state’s newborn screening advising committee, some hospitals continue to batch samples, even though it is the state – not the individual hospitals – that pay to have the blood samples sent to the lab.

A case turned tragic illustrates the problem with waiting to send these blood samples.  We can capture the cause-and-effect relationships that led to a baby suffering brain damage within a Cause Map, or visual root cause analysis, which allows a detailed examination of the issues that led to the nearly fatal outcome.

On October 2, 2012, a baby was born at a Wisconsin hospital.  Per guidelines, a blood sample was taken for newborn screening when the baby was 32 hours old.  However, that blood sample (likely due to batching, though the hospital has not officially confirmed this), was not sent to the state lab until October 8.  The state lab tested the sample October 9 and determined that the baby had Argininosuccinic aciduria, which occurs in only 1 of 70,000 babies in the US. Though it can be fatal, if it’s caught early, the treatment involves some extra care with feeding and an extra day or two in the hospital.

In this case, because the sample was delayed, a diagnosis wasn’t made before the baby had lapsed into a coma.  He was transferred first to a larger hospital, then to one of two hospitals in the state that can perform newborn dialysis – necessary due to his off-the-charts ammonia levels.  A quick-thinking doctor utilized a novel technique of cooling that baby, which saved his life.  The cost of all this treatment was nearly $500,000 and the baby has suffered brain damage, though the extent is not known.

The Journal Sentinel has published data showing how long samples took at Wisconsin hospitals in an attempt to raise public consciousness of this issue.  The state, as well as other experts, continues to advise hospitals of the importance of sending blood samples to the lab for screening within the recommended 24 hours.  It could save a life.

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