Root Cause

A prescription to end unintentional drug poisoning

By Kim Smiley

According to the CDC, drug poisoning is now the second leading cause of unintentional death, after car crashes.  Most of the drug poisoning deaths result from the abuse of illegal and prescription drugs.  If we look at an extremely basic cause-and-effect for overdose of prescription drugs, we note that a patient overdoses (takes too many pills) for some situationally-dependent reason (such as increasing the amount of medication to provide additional benefit, as can occur with painkiller addiction) AND access to an increased amount of the medication.  Many times the access to the medication is provided by “doctor-shopping”, where a patient sees multiple doctors for painkiller prescriptions. 

Databases that track these sorts of prescriptions have been implemented in most states to curb access to large amounts of the most frequently abused drugs.  However, since the programs are state-run, patients could still get multiple prescriptions by crossing state lines.  Also, in some states it may take as long as two weeks before a new prescription shows up in a database, creating extra time for addicts to collect prescriptions.

This is an example of a case where a solution has been implemented, but it  hasn’t reduced the risk to an acceptable level (as evidenced by the thousands of people still dying from prescription drug overdoses).  So, the solution is being tweaked.  The federal government has provided funding to states to upgrade their databases.  It’s hoped that this will start to decrease the number of deaths from prescription drug abuse.  If it doesn’t, even more drastic action will be needed.

Root Cause

Which ankle needs surgery? Neither? Oops . . . (Wrong Procedure)

By ThinkReliability Staff

A patient receiving the wrong procedure is a very serious event. It has been named a “never event” by The Joint Commission. For organizations that are trying to prevent these kinds of serious events from happening, there is value in looking at near misses, such as the case we’ll examine here in a root cause analysis. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

In our case, a patient was prepped for a surgery he didn’t need, even receiving spinal anesthesia. He was prepped for a procedure based on the advice of an orthopedist, who believed the patient to have an ankle trimalleolar fracture, which he did not.

Why did the orthopedist believe the patient to have a fracture? The radiologist who had reviewed the patient’s radiographs diagnosed the fracture. The orthopedist did not review the radiographs. The orthopedist did examine the patient’s ankle, but gained no new insight into the diagnosis. Additionally, the family/patient did not mention the previous diagnosis, possibly because they weren’t told of it, or didn’t understand it..

The radiologist diagnosed the fracture because there was a fracture shown on the radiographs, which were labeled with the patient’s name. However, it was later determined that the radiographs were actually of a previous imaging client. The radiographs were taken because the patient’s previous radiographs did not arrive in time.

Given no more information about this case, our analysis stops here. However, the next step for the medical facility involved would be to examine the radiography procedures to ensure that mislabeling incidents do not occur. Other causes listed in the map can also be examined, to determine where other improvements can be made.

Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals..

Root Cause

Patient Killed By Operating Room Fire

By ThinkReliability Staff

In a previous blog, we looked at possible causes of patient burns, including operating room fires.  Sadly, on September 8th, a patient passed away, six days after being burned during surgery.  (See the news article.)  Due to patient safety laws and ongoing investigations, there is no information suggesting what could have been the causes of the fire.  However, as with any fire, an operating room flash fire, like the one suspected in this case, requires 3 things:

1)  a heat source – typically in the operating room the heat source is provided by electrical surgical equipment.

2) oxygen – patients under anesthesia may be receiving 100% oxygen, providing an extremely oxygen-rich environment for fires.

3) fuel – the disposable synthetic fabrics primarily used now are more flammable than cloth drapes.

Since all three of these causes are required for a fire, removing any one of the causes will prevent a fire.  However, in an operating room environment it’s not practical to remove any one of these causes, so instead we can work on reducing the risk by mitigating the effect of each of these causes.  To reduce the risk from the heat source, surgeons are warned to leave electrical tools in standby mode, or turned off, whenever they are not in use.  To reduce the concentration of oxygen in the air, anesthetists may be asked to provide only as much oxygen as needed for the patient, and avoid creating places that oxygen may concentrate, such as under the drapes.  More flame-resistant material is being considered for use in some operating rooms.  Additionally, more and more operating room teams are providing training in preventing and extinguishing surgical fires, because although only an extremely small percentage of surgeries result in fire, the results can be catastrophic.

Root Cause Analysis

Childhood Obesity – A Community Problem

By Kim Smiley

It takes a village to raise a child . . .and to keep one from becoming obese. Childhood obesity is now being recognized as, at least partially, a community problem with community-based solutions. At the peak of the “obesity epidemic”, 32% of children in the U.S. were classified as overweight and 16% were classified as obese.

Obesity can result in a greater risk of disease (more than 90% of overweight children have at least one avoidable factor for heart disease.) This is an impact to the health goal of a community, and the nation. Obesity is the result of sustained weight gain. Weight gain is a simple balance problem. If calories consumed are greater than calories expended, as a result of too many calories consumed, too few expended, or both, weight gain will result. Usually obesity is caused by both.

First we’ll look at the causes of consuming too many calories. Too many calories are consumed when children eat high-calorie, low-satisfaction foods. In many cases, this is because a child has access to these types of foods and because healthy choices are not available. This is true with family, and at school, which generally contribute equally to caloric intake. A high proportion of foods consumed at school may be unhealthy; schools must offer healthier choices. Some schools have done away with soda and candy, but more healthy choices must also be offered. Students bringing their own lunches may suffer doubly from healthy food not being available at home, due to a lack of access or affordability. The all-too-many areas in the country that do not have access to healthy food at supermarkets or farmer’s markets are known as “nutritional deserts”, most frequently found in low-income and/or rural areas. Communities must improve access to healthy food, at school and at home.

The other part of the equation is calories consumed, otherwise known as exercise. However, children don’t need time on the treadmill; they need safe places to play outdoors or a safe route to walk or bike to school in order to get exercise. They also need physical education (PE) at school, and they need to see the importance of physical activity (something their parents may not be modeling at home, based on adult obesity rates, which are extremely high as well). Low-income and/or rural areas are less likely to have safe places to play outdoors, or a safe way for children to bike/walk to school, so these children are disproportionately affected by obesity. Communities must provide an outlet for physical activity for children.

On the downloadable PDF (download by clicking “Download PDF” above), we show the causes and solutions in a Cause Map, a simple intuitive format that fits on one page. The causes are solutions shown here are from the perspective of the community – causes and solutions that can be controlled by a community. If communities began implementing these solutions, the childhood obesity epidemic would be a thing of the past.

Want to learn more? See the Institute of Medicine report, issued in 2007.

Root Cause

Sorry alone doesn’t work unless we learn from our mistakes.

By ThinkReliability Staff

The title is a quote from Timothy McDonald, a pediatric anesthesiologist and the chief safety officer of the University of Illinois Medical Center, discussing medical errors, which are now estimated to kill as many as 98,000 Americans a year.

“We have to also make promises that this won’t happen again and get patients and families engaged in the effort to improve our performance.”

The University of Illinois Medical Center, along with other medical facilities, has made great efforts to communicated with grieving family members after medical mistakes, and getting those family members involved with helping prevent future mistakes.

One of the changes implemented requires an x-ray of patients at risk for foreign objects retained after surgery. So far, the x-rays have found 8 foreign objects found left in patients , despite a manual count that claimed all the sponges were accounted for.

Some experts worry that the “increased candor” with families may increase the number of lawsuits. Dr. McDonald says that, though the number of procedures at the University of Illinois Medical Center have increased 23% since the program was implemented, the number of lawsuits has decreased 40%.

To many family members of victims of medical errors, it’s not about the money; it’s about making sure nobody else will suffer from the same mistake. Allowing these family members (or the victims themselves) to help improve the processes that led to the errors may ease their concerns. (View the news article in the Wall Street Journal.)

Root Cause Analysis

Emergency Generators: A Loss of Power Doesn’t Mean a Loss of Life

By ThinkReliability Staff

If you are working at a healthcare facility, you most likely have an emergency generator. However, that emergency generator probably powers only certain critical sections of the facility, and it probably doesn’t include the administration part of the building. Why is that so?

We can look at impacts to the goals to determine why a solution that’s successfully implemented to solve a problem at one location or organization may not be the right solution for another organization. In a hospital, a loss of power could impact the goals pretty severely – the risk of death to the patients impacts the safety goal, the loss of life-saving equipment impacts the customer service goal. Additionally, the production goal may be impacted because the facility is unable to enter new patients. Last but not least, an additional cost (impact to the materials/labor goal) may be incurred transferring patients to a new facility. Obviously the risk of death means a HUGE impact to the organization’s goals, demanding comprehensive reliability solutions.

Compare this to an office building, such as where our administrative offices would be. If a loss of power occurred, the goals would be impacted – employees could get injured leaving the building if the lights went out. This is an impact to the safety goal. We may lose our business function during the outage, which would be an impact to the customer service and production goals. Additionally, we may have to pay our employees for a non-work day. The goals are impacted, but the severity of the impacts pales compared to the impacts of a hospital or medical facility losing power.

If we create a Cause Map based on these impacts to the goals, it shows that all the impacts to the goals tie back to a loss of electrical power, caused by both a power outage AND a lack of back-up electricity source. (The Outline and Cause Map are shown on the downloadable PDF.)

When determining solutions, there are a few that come to mind, including transferring patients to another healthcare facility (which becomes an impact to the goals) and installing battery backups in equipment. However, because of the severe impacts to the goals, a hospital will likely decide that the whole problem can be solved by installing an emergency generator. Problem solved; we have been able to find the best solution.

The administrative offices may feel differently. The cost of installing an emergency generator is large, and if we compare that cost to the costs that would be incurred due to a loss of power without backup, it’s probably not worth it. Instead, the office building may implement solutions further to the left on the Cause Map, such as installing emergency lighting, or using battery backups, that would mitigate (but not prevent) the impacts to the goals. So, just because a solution was the “right” solution in one case, it may not be in every case.

View the Outlines and Cause Maps for both the hospital and office building by clicking “Download PDF” above.

View the Joint Commission’s article on Power System Failures.

Never Event, Root Cause Analysis

We Regret to Inform You We’ve Removed the Wrong Leg . . .

By ThinkReliability Staff

Performing surgery on the wrong body part or wrong-site surgery is a “never event” as defined by the National Qualify Forum (NQF), and can have serious health consequences for a patient.

We can use a Cause Map to determine some ways to prevent wrong-site surgery. Some of the common errors leading to wrong site surgeries are presented in the Cause Map found on the downloadable PDF. They include: time pressure, lack of paperwork, misreading radiography, not marking or incorrectly marking the surgical site, and marking the wrong site.

Once the root cause analysis is complete, solutions are brainstormed and placed with the cause they control. In this example, we use the solutions to create a basic Process Map for the surgical preparation procedure to prevent wrong site surgeries. The solutions are numbered based on the order they appear on the Process Map. It’s clear that consistent adherence to this Process Map would result in fewer wrong-site surgeries.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map.

Go to Root Cause Analysis Healthcare Home Page

Hospital Acquired Condition, Root Cause Analysis

UTIs: Painful for the Patient AND the Hospital, too!

By ThinkReliability Staff

According to Medicare data, there were 12,185 cases of Catheter-Associated Urinary Tract Infections (UTIs) in the year 2007, which resulted in an average $44,043 hospital stay. These cases represent more than $500 million in this preventable, hospital-acquired condition. As a result, Medicare and Medicaid will no longer cover costs associated with UTIs if they were not present at admission to a medical facility.

In order to work at preventing these conditions, first we must examine how they occur. We’ll do this by looking at Catheter-Associated Urinary Tract Infections in a visual root cause analysis (or Cause Map).

A UTI is an impact to our patient safety goal. A UTI is caused by pathogens accessing the urinary tract and not being removed. We will look at each of these causes in more detail. Pathogens access the urinary tract when a urinary catheter is inserted. The catheter may be used for obtaining urine, because a patient is incontinent, or to permit urinary drainage.

In order for pathogens to access the urinary tract on a catheter, there must be pathogens on or in the catheter. These can be pathogens already in the body, contamination from the drainage system, or pathogens transferred on the hands of medical personnel, or by a non-sterile insertion.

The pathogens are not removed from the body either because of an insufficient immune response caused by damage to the urinary tract by improper insertion or improper securing of the catheter. Or, the pathogens are not excreted due to an obstructed urinary flow.

Once we have determined the basic causes of a UTI from our simple root cause analysis, we can consider solutions associated with the causes. For example, if a cause is “Pathogens on hands of medical personnel”, a solution may be to require “Handwashing before and after manipulation of catheter site or apparatus.”

Click on “Download PDF” below to see the Cause Map and possible solutions. If facilities began implementing some or all of these solutions, the incidence of Catheter-Associated UTIs would decrease, and patient health and satisfaction would increase.

Root Cause

Implement Solutions Within Your Sphere of Influence

By ThinkReliability Staff

The Houston Chronicle reports disturbing news on the state of healthcare safety and reform.    They reported that:

“Experts estimate that a staggering 98,000 people die from preventable medical errors each year”

“A federal Centers for Disease Control and Prevention study concluded that 99,000 patients a year succumb to hospital-acquired infections. Almost all of those deaths, experts say, also are preventable.”

Not only do almost 200,000 people a year die from preventable errors or infections acquired in hospitals, but, according to expert federal analysts, the rate of these deaths may actually be increasing.  Part of the problem is that the recommendations provided by experts, federal and private studies and various other resources are not being implemented quickly – or at all.

Some people think that the root cause analysis investigation process ends when solutions are recommended.  In fact, the hardest part may be just beginning.  There’s a reason we refer to solutions as “action items” – they require action.  They also require follow-up.

Proper follow-up will determine if solutions are being effectively implemented, i.e. the problem is being solved.  In this case, that would be the number of medical errors are decreasing.  Since that’s not happening, the next step is to determine why the action items were ineffective.  Right now, the recommended action items aren’t effective because they aren’t being implemented.

An organization can only effectively implement solutions that are within its sphere of influence.  Medicare, for example, is attempting to influence medical errors by using its most effective weapon – its pocketbook.  Medicare is no longer reimbursing for certain medical errors, and hopes to add to the list.  As many private insurers follow suit, more healthcare facilities will find it necessary to change the way they do business . . . and then hopefully the medical error rate will begin to decrease.

Learn more about finding solutions.

Root Cause Analysis

Fighting Back Against Drug-Resistant Malaria

By ThinkReliability Staff

A study published in the New England Journal of Medicine shows that malaria is becoming resistant to the most effective anti-malarial drugs currently available, known as artemisinin-based combination therapy. This therapy involves two drugs – artemisinin, which acts and leaves the body quickly for a “shock” to the parasites that cause malaria, and mefloquine, or another related drug, which stays in the body longer and cleans up the rest.

Since there are currently no equally effective replacement drugs or a vaccine for malaria, an increase in the drug-resistance of malaria may increase the number of deaths from malaria. In 2006, malaria was responsible for nearly 1 million deaths, according to the World Health Organization (WHO).

A Cause Map built using a root cause analysis template can visually explain the causes leading to drug-resistant malaria in a simple, intuitive format that fits on one page. (To view the Cause Map, click on “Download PDF” above.)

A risk in the increase in deaths from malaria is caused by people being infected by malaria, and ineffective malaria treatment. Nearly 250 million people a year are infected with malaria, due to exposure to mosquitoes in an endemic area, no vaccine and no preventive drugs (which are expensive and can have side effects with long-term use). Ineffective malaria treatment can be due to counterfeit drugs, which are estimated by WHO to comprise up to 40% of the drug supply. Counterfeit drug distribution is increasing due to a lack of security of the drug supply.

Additionally, the increase in drug-resistant malaria means that existing treatments are less effective. (Counterfeit medicines are a double whammy in that they also contribute to drug resistance.) Drug resistance generally occurs when an infected person takes a not-quite-whole course of treatment. The treatment kills off most of the bugs, leaving only those strong enough to resist. When these “super” bugs then reproduce, the resulting generations are more likely to be drug resistant. (This is what’s been happening in the U.S. with some antibiotics.)

The most effective (and WHO recommended) course for malaria is the combination therapy discussed above. Unfortunately, the mefloquine class of drugs have severe adverse side effects, including nausea, vomiting, and nightmares. When the two medications are given separately, some people chose not to take all (or any) of the mefloquine to avoid these side effects. A possible solution is to only offer the two together, in a combination pill.

The WHO and other organizations continue to work on this problem. An experiment in Europe recently used weakened mosquitoes as “flying vaccines” for malaria, with some success. Until then, the use inexpensive preventive measures such as mosquito nets and indoor spraying continues to increase.

To learn more about diseases carried by mosquitoes, see our yellow fever blog posting.