Tag Archives: best solutions

Root Cause

Hospital reduces neonatal fatalities by 50%

By Kim Smiley

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

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

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

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

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

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

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

Root Cause

Anesthesia Without Electricity or Oxygen Tanks

By Kim Smiley

Almost 32 million surgeries are performed globally each year without a proper supply of oxygen and anesthesia, predominantly in developing nations.  Many more surgeries are canceled or delayed because anesthesia isn’t available.  One of the issues that plague hospitals in low income countries is that traditional anesthesia machines need electricity and oxygen tanks to function, both of which can be in short supply. A new design, called the Universal Anesthesia Machine (UAM), can operate without electricity or oxygen if necessary and is proving to be a practical solution to this difficult problem.

The UAM was invented by a doctor, Dr. Paul Fenton, who worked as an anesthesiologist at Queen Elizabeth Central Hospital in Blantyre, Malawi where he saw the problems with providing adequate anesthesia first-hand.  He designed his machine to use electricity when it is available, but to continue to function if power is lost by using a hand-powered pump on top. A digital display of oxygen levels switches to a 10 hour battery when power is lost so that the patient can continue to be monitored.  It also uses a compressor and air from the room so oxygen tanks aren’t required.

In an effort to make the UAM as practical to use as possible, it doesn’t use specialized parts.  Parts needed to maintain the machine should be available through a typical auto supply shop.  It’s also a flexible design that is compatible with all standard adult and pediatric breathing systems.

Honestly, this invention sounds too good to be true, but the UAM seems to be functioning as promised.   The number of UAMs in use is still relatively small (100 have been distributed to 18 countries), but they have already provided oxygen for over 30,000 surgeries.  Inadequate anesthesia is a huge issue, but this new machine may very well prove to be an important step in working towards a solution.

Click on “Download PDF” above to see a Cause Map of the problem of inadequate anesthesia.  You can also learn more about how the Universal Anesthesia Machine works by clicking here.

Root Cause

Chronic Obstructive Pulmonary Disease (COPD) is Strangling Nation’s Health

By ThinkReliability Staff

The facts about chronic obstructive pulmonary disease (COPD) aren’t pretty.  COPD is not one but a group of diseases that impact airflow and breathing.  Included in the group are emphysema and chronic bronchitis.  (These diseases are grouped together because they are commonly diagnosed together.) COPD is the third leading cause of death.  In 2010, it was the cause of death of 135,000 Americans.  Every year, COPD results in millions of visits to the doctor’s office or emergency room and hundreds of thousands of hospitalizations, which last an average of almost five days.

All that medical care doesn’t come cheap.  COPD is the fifth most expensive disease in the US, with $32.1 billion in direct medical costs.  (In addition, billions of dollars are attributed to absenteeism and mortality costs as a result of COPD.)  An additional concern is that many COPD sufferers are rehospitalized soon after release.  COPD is the third most common cause of 30-day rehospitalization.  Under the Hospital Readmissions Reduction Program (HRRP), penalties or loss of benefits are applied to hospitals with greater than average rehospitalization.  The penalty for readmission of COPD patients beyond average is $33,000.  Of US hospitals, 44.5% received readmissions penalty in 2013.

Because there is no cure for COPD, limiting rehospitalizations primarily involves ensuring appropriate treatment to limit symptoms, and exacerbations, which account for 50-75% of medical costs.  However, there are actions that can slow the progression of COPD.  By diagramming the cause-and-effect relationships resulting in progression of COPD in a Cause Map, we can visually show how solutions act on these causes.  As discussed above, impacts to goals associated with COPD include patient safety (deaths), environmental (exposure to air pollutants), compliance (potential for penalties/ loss of benefits), patient services (high levels of rehospitalization), operations (absenteeism) and property/labor (direct medical costs).  These impacts are primarily caused by exacerbation of COPD.

Exacerbation of COPD results from the progression of the disease and delayed treatment.  COPD develops due to exposure to air pollutants (primarily tobacco smoke or industrial chemicals), genetic factors (which are just beginning to be understood), and respiratory infections or untreated asthma.  Because there is no cure for COPD, time without treatment is the primary way that symptoms increase.  (82% of COPD sufferers are over age 65.)  Inadequate treatment typically results from the underdiagnosis of COPD (experts predict 10-12 million sufferers have not yet been diagnosed) and insufficient adherence to a medication regime.  Based on self-reported values and pharmacy claims, adherence to prescribed medication regime is 32-50%, meaning less than half of COPD sufferers are following doctor’s orders with regards to their COPD, even though studies have also found that optimized medications can reduce exacerbations of COPD by 20%.

Along with underdiagnosis, a cause of exacerbations is delayed treatment.  Part of this is also caused by insufficient adherence to a prescribed medication regime, but also to delayed reporting.  Symptoms of an exacerbation generally occur about a week prior to a discernible reduction in lung function, but all too often that week is spent without medical care because patients tend to delay reporting symptoms until their lung function is affected.

To reduce the impact of COPD as well as the potential for rehospitalization, the following is recommended:  First, the biggest impact an individual can have on COPD is to stop smoking.  Individuals should also reduce their exposure to air pollutants, including cigarette smoke and industrial chemicals (whether at the work place or in home cleaning products).  Those experiencing an exacerbation of symptoms should report it immediately and should follow all medication guidelines given by their doctor.  For doctors, guidelines for the use of spirometry (a breathing test to measure lung function) can provide a more accurate diagnosis of COPD.  Presenting information to patients about the importance of the above measures can also help reduce COPD exacerbations and potential for rehospitalization.

To view a one-page PDF with an overview of the cause-and-effect relationships, and recommended solutions for minimizing the impact of COPD, please click “Download PDF” above.    Or, visit the COPD Foundation to learn more.  You can also view a Cause Map of America’s Smoking Epidemic, here.

Root Cause

Ebola Outbreak Claiming Lives of Medical Staff

By ThinkReliability Staff

On July 29, 2014, the ongoing Ebola epidemic in west Africa was hit a hard blow when Dr. Sheik Humarr Khan, a leading doctor who treated Ebola patients and  national hero in Sierra Leone, died from the deadly virus.  The outbreak, which began this spring, has now infected thousands and killed nearly 900 people across Sierra Leone, Liberia, Guinea and Nigeria, including more than 90 healthcare workers who were treating victims.  It’s the most widespread and deadliest yet, due to the relative ease of travel and an apparently new strain of the disease.  (Read our previous blog about the outbreak.)

Because of the deadly and quick-spreading nature of the Ebola virus, many precautions are taken to protect healthcare workers from the disease.  Says Marie-Christine Ferir, the Emergency Coordinator of Médecins Sans Frontières/ Doctors Without Borders, “As well as the personal protective equipment that our staff wears, we have a series of strict procedures and protocols.  Our treatment centers are designed to ensure the safest possible working environment for our staff.”  Adds Dr. Tom Frieden, the Director of The Centers for Disease Control and Prevention (CDC), “We work actively to educate American health-care workers on how to isolate patients and how to protect themselves against infection.”

Yet workers are still getting sick – and dying.  In an interview with Armand Sprecher, the medical advisor to Doctors Without Borders, he noted that, though the suits worn by healthcare workers when dealing with infected patients are impervious to fluid, procedures and protocols still have to be followed.  For example, wearing or taking off the suit improperly can cause fluid transfer to the face, or hands, which then may touch the face.  An accidental needle stick can also result in a transfer of fluids that can lead to infection.

Now people in other countries are concerned Ebola may spread further.   In order to give stricken healthcare workers the best shot possible, they are generally returned to their home countries for treatment, raising concerns that their presence will allow the virus to take root there.  An American doctor and nurse were returned to the United States for treatment on August 2nd and August 4th, respectively.  Officials note that every precaution is being taken to isolate the patients and that Ebola can be spread only by bodily fluids, which requires very close contact.

Though there are no vaccines or currently approved treatment for Ebola, the infected American personnel received experimental treatment while still in Liberia. The treatment attempts to use antibodies produced by animals exposed to Ebola to help the immune system fight off the virus.  Dr. Brantly received a blood transfusion from a boy who survived Ebola under his care (surviving Ebola appears to provide immunity against re-infection).  Both vaccines and treatments are in development, but funding is difficult given the relative rarity of Ebola.

In the ongoing attempt to contain the spread of the virus, Sierra Leone has quarantined neighborhoods, cancelled public meetings and overseas trips, while Liberia has closed schools, most borders, and put state employees on leave.  The CDC has issued a Level 3 Travel Warning to Guinea, Liberia and Sierra Leone.  The World Health Organization has launched a $100 million campaign with the aim of bringing the epidemic under control, partially by providing new doctors.

To view the impacts this disease is having on the public as well as healthcare professionals, the causes of these impacts and what is being done to reduce the risk of these impacts, please click on “Download PDF” above.  Or read our previous blog to learn more about the outbreak.

 

Root Cause

Solving the Problem of Organ Donation

By ThinkReliability Staff

6,570 Americans die every year waiting for a donor organ.  Says Johns Hopkins surgeon Dr. Andrew Cameron, “There just aren’t enough organ donors to go around.  That’s not a medical problem.  That’s a social problem.”  Though 95% of people support organ donation, only 40% are registered organ donors.  For the over 123,000 people on the waiting list, there just aren’t enough donor organs to go around.

This issue can be addressed within a Cause Map, a visual root cause analysis.  The first step is to capture the “what”, “when”, and “where of the incident, as well as the impact to the goals.  In this case, the problem is lack of donor organs available, causing patient deaths.  Though the problem exists everywhere, the focus of this blog will be on ongoing organ shortage in the United States.  Important differences in the United States related to organ donation are that only 40% of Americans are registered organ donors (despite widespread public support), and that there is no central registry of organ donors within the United States.  (Organ registries are typically state-run.)

The large number of deaths resulting from inadequate donor organs is an impact to the patient safety goal.  The delay in receipt of organs can be considered both an impact to the patient services and schedule/operations goal.  The lack of available organs can be considered an impact to the property goal.

To develop the cause-and-effect relationships that led to the impacted goals, we ask “why” questions.  In this case, the patient deaths result from the need for donor organs due to disease or injury, and the delay in receipt of organs.  The delay in receipt of organs is due to a lack of available organs.  Millions of Americans die every year, and while not all organs are acceptable for transplant, more than one organ can often be used from donors, resulting in multiple lives saved from each donor.

In an interesting cause-and-effect result, increased traffic safety has resulted in fewer fatal traffic accidents of young, healthy people, which has led to a decrease in available donor organs.  Of course there is no effort to try and increase organ donation by stopping the decrease of deaths of young people.

The shortage of donors from people who are eligible (upon death or brain death) result from not signing up for the organ donation registry and/or from a family not choosing to donate organs.  There are multiple reasons suggested for people not choosing to register or donate organs.  To solve the problem, companies are working on increasing the number of donors.  Dr. Cameron coordinated with Facebook to allow users to register as organ donors and saw the number of organ donors go up “22 fold”.  Says Dr. Cameron, “That’s proof that we can move the needle.”  The startup Organize is “building a portfolio of technology that makes it easier for people to demonstrate their desire to be an organ donor.”  The company hopes that it will improve organ donation to the point that it puts itself out of business in five years.

To view the overview of the organ donation problem and solutions, click on “Download PDF” above.  As discussed in a previous blog, work is also being done to increase the number of organs that are acceptable for donation (in this case with kidneys).

Root Cause

Study Finds Bacteria Can Live on Airplane Surfaces for Days

By Kim Smiley

With many bodies packed into a tight space and seemingly stale air, airplanes tend to bring out the inner germaphobe in many of us.  And the latest research, especially if you just read the headlines, isn’t going to help. Researchers at the University of Auburn found that Methicillin-resistant Staphylococcus aureus (commonly known as MRSA) and E. Coli can live for days on airplane surfaces.

The experiment involved sterilizing six surfaces found on airplanes (seat pocket, arm rest, leather seat, window shade, tray table and toilet handle), introducing MRSA and E. Coli bacteria to them and then measuring how long the bacteria survived.  Typical conditions inside an airplane were stimulated and the bacteria were suspended in three different solutions (saline, simulated seat and simulated saliva) to replicated the environment inside an airplane. The survival times ranged from 8 to 2 days.  This is a little scary, especially since an estimated 1-2 percent of people in the US may be carriers of these dangerous bacteria.

The good news, and there is good news, is that the surfaces where the bacteria lived the longest, the more porous surfaces such as the seat pocket, are the least likely surfaces to actually spread the contamination.  The study also didn’t look into how much bacteria remained after the typical cleaning  by airlines between flights, but the researchers plan to look into this in the future.

So what can you do to reduce the risk of illness if you have plans to travel on an airplane soon?  The simplest thing you can do to protect yourself is to frequently wash your hands with soap or use hand sanitizer as well as avoid touching your face as much as possible.  If you feel the need to take additional precautions, you can clean the areas around your seat with a disinfectant when you board the plane.

Airline cleaning procedures can also significantly impact the spread of illness.  So the question is, how much do you trust the thoroughness of the cleaning performed by the airline?  I think I may invest in a travel-size hand sanitizer before my next flight.

To see a high level Cause Map of this issue, click on “Download PDF” above.

Root Cause

Stroke Treatment Inadequate in Many Cases

By ThinkReliability Staff

Research presented at the American Stroke Association’s International Stroke Conference 2014 showed that although 81% of people in the United States lives within an hour’s drive of a hospital equipped to treat acute stroke, only 4% received tPA, a drug which can reduce disability if given within 3-4 hours of the first stroke symptom, and the only drug approved by the FDA to treat stroke.

Researchers reviewed the records of 370,000 Medicare stroke claims from 2011.  (Annually in the United States, 800,000 people suffer from stroke.)  The low percentage of patients receiving the recommended (and only) treatment for stroke is a significant impact to both the patient safety goal (because of the disability that could be avoided with proper treatment) and the patient services goal, because so many patients are not getting adequate treatment after a stroke.

There are many challenges involved in administering tPA within the recommended time frame.  Administration is ideally done within 3-4 hours of the first stroke symptoms, but faster is better.  As the study‘s lead author, Dr. Opeolu Adeoye, M.D., M.S. states, “Every 15-minute delay in getting treatment increases the odds of that patient not being able to go home.”

Although 4 out of 5 patients live within an hour’s drive of a designated stroke center, a hospital which is equipped to treat stroke (and not all hospitals are), that still leaves almost 20% who aren’t.  The drug tPA can’t be administered before imaging confirms the stroke and that it is a non-bleeding-type stroke as administering tPA to patients suffering from a bleeding-type stroke can cause harm.  Even after a patient arrives at a stroke center, delays in imaging and treatment could increase the time before tPA is administered to outside the window.  The study also found that 60% of hospitals did not administer tPA to stroke victims, though it is the only recommended treatment for acute stroke.

Many potential solutions are being studied and implemented to reduce the risk of stroke after disability.

For patients: the best way to reduce the risk of disability from stroke is to prevent having a stroke in the first place.  About 80% of strokes are preventable and due to risk factors, such as smoking or obesity.  Maintaining a healthy lifestyle can reduce the risk of stroke.  If you or a loved one suffers from a stroke, contact an ambulance, as the ambulance will be able to direct you to a designated stroke center.  If you are driving yourself, it’s worth it to go to a designated stroke center, even if that means “bypassing another hospital that isn’t set up to deliver the necessary therapy, ” says Dr. Adeoye.

For paramedics: because paramedics tend to see most stroke patients before they get to a medical center, the search is on for a drug that could be administered prior to imaging (unlike tPA) so that stroke treatment could begin prior to arriving at a medical center.  A study looked at administering intravenous magnesium in the ambulance, but found that it did not improve stroke-related disability.  However, if another drug can be found that would, researchers are hopeful, as the median time for receiving the stroke treatment by ambulance was 45 minutes after symptoms began, and 74% of patients began treatment within an hour.

For medical centers:  The American Heart Association/ American Stroke Association’s national quality initiative Target: Stroke℠ aims to reduce the time between stroke symptoms and treatment.  Since its initiation in 2010, the percentage of patients treated within 60 minutes or less from hospital arrival has increased from less than one-third to more than one-half.  Additionally, the average time from arrival to treatment dropped from 74 to 59 minutes. These faster treatment times have reduced the percentage of stroke patients who died in the hospital from 9.9% to 8.3%.  The improvements were seen in patients regardless of age, sex, or race.

Ideally, the implementation of these solutions – and many more that are in the works – will continue to reduce the risk of, and from, stroke.

To view the Outline, Cause Map and solutions related to inadequate treatment for stroke patients, please click “Download PDF” above.  Or click 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

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

Teen Dies From Peanut Reaction Despite Epinephrine Injections

By ThinkReliability Staff

Even with the best medical treatment known provided quickly after an anaphylactic reaction, a teen died after taking a bite of a snack containing peanuts, to which she was severely allergic. It is important to note that the snack was not clearly marked to contain peanuts and it was a style of treat (Rice Krispies) that would not ordinarily contain peanuts.

In a situation requiring emergency response, it is important to ensure that all the prescribed steps were taken.  The required steps can be diagrammed visually within a Process Map.  In this case, all available actions were taken to attempt to reverse the allergic reaction. (View the Process Map of the appropriate food allergy response by clicking “Download PDF” above.)

For reasons as yet unknown, food allergies have been increasing over recent years.  This has resulted in a greater risk for anaphylactic reactions, which can result in serious injury and even death, usually from throat closure from swelling (known as severe laryngeal edema).

According to John Lehr, the Chief Executive Officer of  Food Allergy Research & Education:  “Avoidance is the only way to avoid a reaction, but we know accidents happen.  That’s the insidious nature of food allergies.”

Because avoidance is the only way to avoid an anaphylactic reaction, many schools and other public facilities have stopped offering any food containing peanuts.  Others have designated peanut-free zones to help those with allergies avoid contact with peanuts.  (Although peanut allergies are not the most prevalent, they are the most dangerous, both from reaction severity and likelihood of contact.)  Certainly, snacks containing peanuts must be clearly marked as such.

Because of the high risk of serious injury or even death from food allergies,  please pass the word about food allergies.  If you are an allergy sufferer, ensure that you have multiple epinephrine auto-injectors that have not expired.  It may save your life.  (Although up to 40% of anaphylaxis victims require two or three epinephrine injections, death after receiving injections is extremely rare.)   Also note, from John Lehr:  “We tell people that their last reaction is not an indication of their next reaction.  Don’t think because you have not had a severe reaction that you can’t have one.”  If you provide food to the public or children, consider removing peanuts from your  kitchen and at the very least, clearly mark anything that does contain peanuts.   Remember, the risk from food allergies is very real, and can be very severe.

You can see the cause-and-effect relationships that led to this tragedy, as well as the Process Map discussing anaphylactic response, in visual form, by clicking “Download PDF” above.  Or click here to read more.