Addressing Systemic Failure at the Nation’s Hospitals

By ThinkReliability Staff

A Medicare analysis (see the news report) has shown that a small (but significant) group of hospitals have much higher than average death rates from pneumonia, heart failure, and heart attacks.  Additionally, the study found that one in four heart failure patients (and a similar but smaller percentage of pneumonia and heart attack patients) have to return to the hospital within 30 days.

Hospitals are in the business of solving problems.  So, what do the results of this study tell us about problem-solving?  Statistics like this point to a systemic failure.  Systemic failure indicates an inability of the system (in this case, hospitals) to achieve their goals (improving patient health).  Although statistics can help determine if there is a problem, statistics themselves do nothing to solve the problem.

A root cause analysis investigation can be a useful tool to determine the causes of systemic failure.  The investigation can be performed by anyone with the authority to effect change – for example, Medicare itself could perform the analysis, with results and associated suggestions for improvements being provided to its associated hospitals.  Or, an individual hospital can perform an investigation itself, using its own data and experience.

This seems like a monumental task – just considering one in four heart failure patients results in a staggering number for any hospital.  However, an investigation of systemic failure does not require an analysis of each individual case.  Instead, begin with one specific case.  Dig up all the information on one patient who returned to the hospital after treatment, and perform a comprehensive root cause analysis investigation on that case.  Because this specific case is part of a systemic issue, properly implemented action items (solutions) will improve the care at the hospital as a whole, thus reducing the number of cases that make up the systemic issue.

Once this has happened, the job isn’t done.  After solutions are implemented, their effectiveness must be verified.  For large systemic issues, implementing action items from one investigation may not be sufficient to “solve” the problem (allow the hospital to achieve its patient health goals).  If this is the case, other specific incidents can go through the same root cause analysis investigation process, one at a time, until the implemented solutions allow the hospital(s) to operate in a satisfactory manner.

Don’t Plug That In! (Preventing Electrocution in Healthcare Facilities)

By ThinkReliability Staff

Patient death or disability associated with electric shock is one of the never events as defined by The Joint Commission. In order to reduce the occurrences of these unfortunate events, we can perform a root cause analysis on an event that has already occurred. This will allow us to apply the lessons learned to keep this type of event from happening at other facilities. 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.

The first step to a root cause analysis is to define the problem. On an unknown date, a patient was electrocuted and killed while undergoing heart monitoring at a medical facility. The heart monitor was plugged in to an IV pump inadvertently. We put the incident in the context of the organization’s goals: the patient safety goal was impacted because of the death of a patient; the staff was devastated, resulting in employee impact, and the compliance goal was impacted because this was a never event.

Once the problem has been defined, we use the impacts to the goals to begin the second step, analysis. Thegoals become the first cause boxes in our Cause Map. We ask “why” questions to fill in the remainder of the map. Here, the patient was electrocuted because she was hooked up to a heart monitor, and electricity flowed through the heart monitor. The electricity was present because the heart monitor lines were plugged into an IV pump, and the IV pump was plugged into the wall. The heart monitor lines were plugged into an IV pump because a staff member was attempting to reconnect the heart monitor and confused the monitor and the IV pump, and the heart monitor lines were able to be plugged in to the IV pump.

The last step is to define solutions. Here, we’ve only put two solutions, though more are possible. One is to change the adapters so that it isn’t possible to plug the heart monitor into another piece of equipment. Another is to institute a lock-out procedure, so that other pieces of equipment in the room are de-energized (if possible) or tagged to prevent confusion.

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.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

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Can a Fire Get You Fired? (Preventing Patient Burns in Healthcare Facilities)

By ThinkReliability Staff

Patient death or disability resulting from a burn received while at a medical facility is a “never” event as defined by the National Quality Forum. Medicare has announced that it will not reimburse medical facilities for treatment required as the result of a burn obtained at that facility. Although there are many different ways a patient burn could occur, we will look at  root causes for some of the more common situations that result in a patient burn.

Serious patient burns can result from exposure to hot equipment (typically an electrosurgical device placed on the patient) or from a surgical fire. A surgical fire, like all fires, requires three things to occur: an oxidizer, fuel, and an ignition source (or heat). In surgery, the oxidizer can be provided by atmospheric air, nitrous oxide, or an oxygen-enriched atmosphere. This leg of the fire triangle is typically controlled by an anesthesiologist.

There are many fuel sources in an operating room. Common operating room material, like drapes, gowns, sterile pads and gauze, is flammable under the right conditions, as are certain volatile prepping solutions and ointments, the patient’s hair, and body gases. Fuel sources are generally under the control of the nursing staff.

The most common ignition (heat) sources in the operating room are lasers and electrosurgical devices. These are generally controlled by the surgeon.

Because the three legs of the triangle are controlled by three different people in the operating room, good communication is essential. There are also some other operating procedures that reduce the risk of a fire. These solutions are shown in green boxes on the downloadable PDF.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

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Patient Falls: A Cause Mapping Example

By ThinkReliability Staff

Patient death resulting from a fall is one of the National Quality Forum’s “Never events” and death or serious disability resulting from a fall is also on the list of hospital-acquired conditions that Medicare/Medicaid will no longer reimburse for. For these reasons, as well as reasons of patient safety, healthcare facilities must work on reducing the risk of patients falling.

Because there are myriad ways a patient can have a fall, we will show an example of a specific case. In this case, a disoriented patient (who was considered a high fall risk) was left alone in an imaging room, without being strapped on, after radiographs were taken. The patient ruptured an eyeball, resulting in blindness in one eye. The medical facility involved received a fine of $25,000.

During the root cause analysis, the facility determined that the policies regarding high fall risks were not followed in this case. As a result, the facility has instituted safety education for the imaging staff, a monitoring process to ensure policies are being followed, and a program whereby a clinical staff member accompanies high fall risk patients to the imaging room. These are the solutions to the root cause analysis.

Although the analysis we performed is specific to this case, the solutions and thought process are not. To reduce falls, every facility should re-evaluate its fall risk program. Are the criteria still valid and being uniformly applied by all staff? Is there more that can be done to reduce the risk of falls? We can help you take a similar incident from your facility to help you improve safety processes.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

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Oh, the Pressure! (Reducing Cases of Stage III and IV Pressure Ulcers)

By ThinkReliability Staff

Stage III and IV pressure ulcers have been added to the list of hospital-acquired conditions whose treatment will no longer be reimbursed by Medicare. Pressure ulcers are also on the list of “Never” events, or incidents that should never occur at healthcare facilities, and can lead to serious complications from patients who suffer from them. It is imperative that healthcare facilities reduce the risk of patients contracting pressure ulcers.

To reduce the risk of pressure ulcers, a root cause analysis can be performed. Not only can we use root cause analysis to determine the causes of incidents that HAVE occurred at our facility, we can outline the ways incidents COULD occur, or, in this case, what is required for a patient to contract pressure ulcers. For this, we use a proactive Cause Map (or visual root cause analysis).

We start our analysis by examining the impact to the goals. There are many impacts to the goals, but we will just focus on two: the patient safety goal is impacted by a patient contracting a stage III or IV pressure ulcer, and the compliance goal is impacted because this is a “never” event. To continue the Cause Map, we ask “What caused this?” and put the answer to the right. So when we ask “What caused the pressure ulcer?” we write “Death of tissue.” We then continue through the Cause Map this same way.

Death of tissue is caused by poor skin condition and mechanical damage to the tissue. Poor skin condition can be caused by a number of things, including poor environment, contaminants on the skin, and inadequate nutrition.

There are three types of mechanical damage to skin that causes pressure ulcers. These are shear, friction, and pressure injuries. Shear injuries can be caused by the head of a patient’s bed being elevated (so that the skin pressed against the bed is damaged as the rest of the body tends to be pulled downwards by gravity). Friction injuries can be caused by skin being drug over skin linens (to reposition an immobile patient, for example) or by bony prominences (such as knees and ankles) contacting each other. Pressure injuries are generally caused by a patient remaining in the same position. Causes of this are lack of knowledge about pressure ulcers, and being unaware of a specific patient’s risk.

There is more detail that can be added to this root cause analysis, but for the purposes of this example we will stop here and begin looking at solutions. Any cause box on the map can have a solution, or several solutions, but not every box will have a solution. Some solutions that have been compiled from various resources are shown in green boxes. Both the Cause Map and solutions can be broken out into more detail, depending on the needs of the organization.

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

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Type AB? Negative. (ABO-Blood Incompatibility)

By ThinkReliability Staff

Blood incompatibility is a Sentinel Event as defined by The Joint Commission. If a blood incompatibility incident occurs at a medical facility, a root cause analysis is required for the event. What would the root cause analysis look like? We will look at a proactive Cause Map (visual root cause analysis) and associated Process Map as an example.

A recipient being given incompatible blood product is an impact to the patient safety goals (as well as other goals, but we’ll start simple). This could occur if the ABO blood type is identified incorrectly, probably due to mislabeling. It could also occur if the recipient’s blood type is identified incorrectly, possibly due to the recipient test specimen being mislabeled. Or it could occur if blood product is given to the wrong patient due to misidentification of the recipient. There are many other ways it could occur, but these three errors are the source of many blood incompatibility incidents.

As we enter these causes into our Cause Map, we note that these are all procedural errors. When procedural errors appear in the root cause analysis, making a Process Map can assist in the investigation. To make a Process Map, we start with the very basic process. For example, to perform a blood transfusion, we order a transfusion, take a sample from the recipient, test that sample while prepping the patient for a transfusion, pick up blood product from the blood bank (which was deposited there at some point previously), perform the blood transfusion, and then monitor the recipient for reactions.

Then we go into more step by step detail outlining portions of the transfusion process. Then we can identify the specific steps of the procedure that can lead to blood incompatibility incidents when performed incorrectly. This allows us to come up with procedural solutions (such as having a second medical professional positively identify the recipient) that focus our attention on the steps most likely to be performed incorrectly or most likely to lead to serious errors.

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

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Another Bubble You Don’t Want to Be Part Of (Air Embolisms)

By ThinkReliability Staff

Air embolism (an air bubble trapped in the blood vessels) in hospital patients is one of the “never” events that will no longer be reimbursed by Medicare. It can also cause patient death, stroke, heart attack, or other serious complications. Thus it is in the best interest of medical care facilities to reduce the occurrence of air embolisms. In order to do this, first we must determine the causes of air embolisms. We will do this as a root cause analysis example.

Many people think of root cause analysis as a tool to determine what WENT wrong, but it can also be used to determine what COULD go wrong. We will look at the issue of air embolisms in a Cause Map to determine the causes, and then the solutions that can be implemented to reduce the occurrence of air embolisms.

For step 1, we outline the problem. The problem here is air embolisms. They affect the vascular system and often occur during surgery or as a result of using a catheter. Air embolisms impact the patient safety goal because they can cause tissue damage, serious injury, or even death. It impacts the compliance goal because it is a “never” event, and impacts the materials and labors goal because (according to Medicare data) it results in an average hospital bill of over $71,000 (which may not be reimbursed). There are approximately 57 cases/year (Medicare data), resulting in an annual cost of over $4 million.

Step 2 is the analysis. We begin with the impacted goals (we’ll look at the patient safety and compliance goals here). These goals are impacted by an air embolism. For an air embolism to occur (i.e. for air to get trapped in a blood vessel), the vasculature must be exposed to air AND the pressure gradient must favor air entering the blood vessels (normally it would be the other way around – if a blood vessel is opened, blood will come out rather than air going in). The pressure gradient could favor air entering blood vessels if surgery above the heart is performed upright or due to low central venous pressure. This could be caused by decreased blood volume or deep inspiration, such as coughing or laughing (there are case studies of post-surgical patients keeling over after a good joke).

There are several ways the vasculature can be exposed to air. Removing a catheter or performing surgery may expose blood vessels to the atmosphere. Additionally, air can enter the blood vessels through a catheter. This can occur if the catheter is damaged or opened, or if air is forced into the catheter.

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

Once the Cause Map has been completed to desired detail, we can look for solutions. Any cause on the Cause Map can have a solution (or more than one), but not all causes will. Here we’ve identified some of the best practices towards preventing air embolisms.

Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.

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You left WHAT in there? (Foreign Objects Retained After Surgery)

By ThinkReliability Staff

Leaving a surgery sponge (gossypiboma) or other foreign object in a patient’s body can cause serious complications or even death. According to Medicare data, there were 750 such cases in 2007, which cost an average of $63,631 per hospital stay. That’s more than $47 million a year, and does not include potential legal costs associated with such events.

We can examine the problem of post-surgery foreign object retention by putting it into a visual root cause analysis (or Cause Map). A foreign body may be left inside a patient if it is not visible in their body, is not detected by radiography, and is not recognized as missing. We continue to ask why questions to fill out our root cause analysis.

Why would the object not be detected by radiography? The object may not be detectable by radiography, as some sponges are not. The object might not be noticed in the radiography, if the person reading it is not adequately trained, or if there is no double-check. Or, radiography might not have been used. This is contrary to some organization’s recommended procedures.

How would the object not be recognized as missing? The instrument/sponge count may be inaccurate, or it may not have been done at all, which is also contrary to recommended procedure.

Since we have “Did not follow procedure”, we need to outline what the proper procedure should be. We call this a “Process Map”. Here we show the procedure for instrument and sponge removal verification. Instruments and sponges are counted before, and twice after surgery. If the count does not match, there is a physical re-examination, and radiograph to determine whether the object has been left inside the patient. Different organizations may use a slightly different process, but what is important is that it is formalized and examined in the case of any incidents, such as a left-behind sponge or instrument.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map made with our root cause analysis template.

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First Do No Harm

By ThinkReliability Staff

Cause Mapping Example:


Partnership for Patient Safety (p4ps) is a patient-centered initiative to advance the reliability of healthcare systems worldwide. The patient events within the award-winning video series “First, Do No Harm” have been dissected using the Cause Mapping method of root cause analysis.

In this example investigation the cause-and-effect relationships for both patient events are matched to the corresponding breakdowns in the different work processes.

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