Tag Archives: cause mapping

Root Cause

Identifying and Preventing Causes of Lab Errors

By ThinkReliability Staff

A man was mistakenly told he had HIV. A baby who died from a blood disorder that could have been treated during pregnancy, but wasn’t because the routine blood screen came back clear. A little girl who had to receive a second transplant after the test to verify her acceptance of a new organ was run incorrectly. These are just some of the cases mentioned in a watchdog report about how laboratory errors and weak oversight put patients at risk.

There are 7 to 10 billion medical laboratory tests run in the US every year. Lab tests influence about 70% of medical decisions. Having the wrong information from these tests can be deadly, and there is no good data about how many lab tests may be inaccurate, or may be negitively impacting patient safety. Laboratories are generally overseen by accrediting organizations but the results are almost always private, and there have been recent cases where federal regulators have had to step in because serious deficiencies in lab processes were identified.

The risk isn’t just for patients. An employee was infected with HIV and hepatitis C after a machine malfunctioned, splashing contaminated blood product onto her face. The employee had warned her boss previously that the machine was broken and cross-contaminating samples. Patients can also receive wrong information that isn’t harmful to their physical health but causes all sorts of other problems, such as incorrectly run paternity tests that improperly rule out a man as the father of a child.

The process involved in laboratory testing – from taking a specimen from a patient to delivering the results – is complex, and there are potential issues at each step that can lead to inaccurate results. These causes can be visually diagrammed in a Cause Map, or a visual cause-and-effect diagram. (To view the Cause Map, click “Download PDF” above.) In this case, potential causes of lab errors are captured and analyzed for potential solutions. These causes include labeling of samples, time and storage conditions of the samples, use of proper (and non-expired) products to treat the samples, and calibration of the machines used for the testing.

Actions that reduce the risk of inaccurate lab results should be in place at all labs, but even with a well-planned process, mistakes can happen. That makes the addition of checks and oversight into the process incredibly important. Says Michael Baird, the chief science officer and laboratory director at DNA Diagnostics Center, “I will agree that mistakes are something that can happen whatever you do. You just need to have the appropriate controls in place for when a mistake happens, (so) you can catch it before it goes out the door.”

For example, at the lab Baird runs, samples used for DNA checks are run independently by two different technicians and when a man is ruled out as the father of a child, there is a double-check in place. Other labs have incorporated alert systems for time-sensitive specimens and have hired technical directors responsible for overseeing the labs.

There are also steps patients themselves can take to minimize the impact on their safety from potential lab testing errors. First, ensure that any samples taken are labeled immediately and with accurate information. If you’re at all unsure about a test result, get a second opinion at a different lab. Complaints about a lab should be directed to state health officials.

To view the Cause Map addressing potential causes of laboratory errors, click “Download PDF”. To learn more, read the watchdog report.

Root Cause

Measles Vaccine Provides Multiple Protections

By ThinkReliability Staff

For previously unknown reasons, children who received the measles vaccine were less likely to die from infectious diseases other than measles.   According to Michael Mina, a postdoc in biology at Princeton University and a medical student at Emory University, the difference is significant.  “In some developing countries, where infectious diseases are very high, the reduction in mortality has been up to 80 percent.  So it’s really been a mystery – why do children stop dying at such high rates from all these different infections following introduction of the measles vaccine?”

Based on epidemiological data from countries before and after the measles vaccine was introduced, scientists believe they may have an explanation for this mystery that is part correlation and part causation.  So what’s the difference (and why do we care)?

Correlation means that two or more events tend to occur about the same time and might be associated with each other, but aren’t necessarily connected by a cause-and-effect relationship.  Causation means that a specific action causes a second event to happen.  A cause-and-effect relationship results from causation.   Sometimes it’s very difficult to distinguish between the two.  This is where the importance of evidence comes in.

In this case, part of the decrease in death due to infectious diseases can be considered due to correlation.  In this case, children who received the measles vaccine must have had access to healthcare, including the measles vaccine.  If they received the measles vaccine, they were also likely to receive other vaccines and treatment for other infectious diseases, meaning their death rates from other diseases were also lower.  The measles vaccine did not cause the reduction in deaths from infectious diseases, the access to healthcare did.  Getting the measles vaccine also resulted from the same cause, access to healthcare.

In addition to this correlation, epidemiological data from several countries from prior to the introduction of the measles vaccine shows that the number of measles cases predicted the number of deaths from other infectious diseases two to three years later.  Their hypothesis, supported by studies in monkeys, suggest that the measles virus actually erases immune protection to other diseases.  So, if a child gets measles, he or she loses some of the immune system’s “memory” of how to fight diseases can also be wiped out.  Preventing a child from getting the measles (by getting a measles vaccine) is believed to prevent deaths from other infectious diseases as well.

Although more testing is needed to verify the causation, scientists hope it will provide more evidence for parents to vaccinate their children.  Epidemiologist William Moss, who studies the vaccine at John Hopkins University, says “The reduction in overall child mortality that follows measles vaccination is much greater than previously believed.  I think this paper will provide additional evidence – if it’s needed – of the public health benefits of measles vaccine.  That’s an important message in the U.S. right now and in countries continuing to see measles outbreaks.”

To view the cause-and-effect relationships (both correlation and causation) between the measles vaccine and decreased mortality from childhood infectious diseases, please click on “Download PDF” above.  To learn more about the epidemiological study, click here.

Root Cause

Safely using a treadmill is not quite as simple as it seems

By Kim Smiley

Did you know that treadmills are the riskiest exercise machines?  I sure didn’t, but I have to admit that I have fallen off one before.  (Based on conversations with my coworkers, this isn’t all that uncommon.)  As recent headlines have made clear, using a treadmill safely may not be quite as simple as it seems.

According to data from the National Electronic Injury Surveillance System, about 19,000 people went to the emergency room (ER) because of treadmill injuries in 2009, which is about triple the number of injuries reported in 1991.  More and more people are using treadmills and the number of accidents has increased as well. Although only a small percentage of the injuries are serious, about 30 deaths related to treadmill use were reported between 2003 and 2011.

Understandably, the details surrounding Dave Goldberg’s death have not been released to the public, but it is believed that he slipped while using a treadmill and hit his head when he fell.  Falls off treadmills that result in serious injury are rare, but they have the potential to cause significant injury and even death. More common injuries associated with treadmill use are less serious overuse injuries, such as strains and sprains.

Children are at particular risk of being injured by treadmills.  A motor propels the belt on treadmills and children can get their extremities caught in the moving belt or suffer burns if they accidently turn a treadmill on or one is left running while unattended.  Of the 19,000 ER visits associated with treadmills in 2009, nearly a third were for children under age 9.

So how do you stay safe while using a treadmill?  The number one rule is to limit distractions.  Using a phone or watching TV puts you at a much higher risk of accidently misplacing a foot and falling.  (Trying to write an email while I walked on a treadmill is what resulted in my own fall.  Luckily, only my pride was injured, but I have learned my lesson.)

Treadmills have also risen in complexity and all the buttons and options can be distracting, especially if you are unfamiliar with the specific equipment.  Make sure you understand how to use the treadmill prior to starting the belt.  If you have balance issues or are elderly, you should also check with a doctor prior to using a treadmill.  And lastly, start by walking slowly and gradually increase the pace of the treadmill so that you aren’t caught unaware by how quickly the belt is moving.

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

Root Cause

Listeria in Ice Cream Causes 3 Deaths

By ThinkReliability Staff

On April 20, 2015, the Centers for Disease Control and Prevention (CDC) announced a recall of all Blue Bell Creameries products due to possible contamination by Listeria monocytogenes.  While the company has not yet determined the source of the outbreak, they are working with outside agencies to determine potential causes and implementing solutions to reduce the risk of food-borne illness in the future.  Says Paul Kruse, the CEO and president, “We’re committed to doing the 100 percent right thing, and the best way to do that is to take all of our products off the market until we can be confident that they are all safe.  At this point, we cannot say with certainty how Listeria was introduced to our facilities and so we have taken this unprecedented step.  We continue to work with our team of experts to eliminate this problem.”

Performing a root cause analysis can help clarify the goals of an investigation, determine the causes of the problem(s) related to an issue, and provide ideas for action items to reduce the risk of the issue recurring.  We can gather the information known so far about the outbreak in a Cause Map, or visual root cause analysis.

The Cause Mapping process begins by capturing the what, when and where of an incident.  Here, the “what” is the Listeria outbreak.  The “when” in this case is believed to have started in 2010 and continued to the present.  It can be helpful to capture any noted differences about the particular investigation.  For example, most outbreaks don’t last 5 years.  The use of genome sequencing (starting in 2013) allowed investigators to tie Listeria cases from 2010 on to this particular outbreak.  An additional difference is that Listeria can replicate in very cold temperatures.  This is unusual because freezing foods generally reduces the risk of propagating food-borne contamination.  The “where” is across the US – all products have been recalled and all plants have been shutdown, with several having been implicated in spreading Listeria.  Another useful piece of information can be the task being performed.  In this case, the contamination was discovered during random sampling.

The next step is identifying the impacts to the goals.  For this incident, the safety goal was impacted due to the sicknesses and deaths.  The outbreak of Listeria can be considered an impact to both the environmental and customer service goal, while the loss of production (no Blue Bell products are currently available or being produced for consumers) is an impact to the production goal.  The disposal of the estimated 8 million gallons of ice cream covered by the recall impacts the product goal, and the response and investigation impacts the labor goal.

The analysis step begins with an impacted goal.  Asking “why” questions develops the cause-and-effect relationships that led to the impacts.  In this case, the sicknesses and deaths were caused by a Listeria outbreak.  In order to have a food-borne illness outbreak, the food needs to be contaminated AND it needs to be delivered to consumers.  In this case, the contamination was not known because ice cream is not tested for Listeria.  There is no history of Listeria outbreaks in ice cream and testing is difficult on perishable products because of the time required.  Once ice cream products are again manufactured for consumers, Blue Bell has said it will implement a test and hold process (holding product until testing comes back negative).

The Listeria contamination results from the introduction of Listeria into the ice cream.  As discussed before, Listeria can replicate in cold temperatures.  The contamination source is likely surfaces in the production facilities or cross-contamination from other food products.  Because multiple plants are contaminated and cleanliness issues have been a concern in the past, it is likely that the outbreak is due to contamination of surfaces, on which Listeria can remain for a long time if not properly sanitized.

In addition to the test and hold process, Blue Bell is in the process of implementing a number of other changes to reduce the risk of future contamination.  Employees are being trained in microbiology and an expanded cleaning and sanitation program.  Prior to production resuming, equipment is being disassembled, cleaned, and tested for contamination and design changes that would make cleaning easier (reducing the risk of future contamination) are being considered.

While it is sometimes difficult to determine the success of solutions, the test and hold process to be used for future ice cream products should provide almost real-time feedback on the success of the programs and ensure that future problems are quickly identified.

To view a one-page PDF of the analysis and solutions, please click on “Download PDF” above.  To learn more about the ice cream Listeria outbreak, click here.  To read our previous blog about the 2011 fatal Listeria outbreak in cantaloupe, click here.

Root Cause

With $16.3B, Why Are Veterans Still Waiting for Care?

By ThinkReliability Staff

Concerns regarding the timeliness of treatment within the Veterans Administration (VA)’s network of hospitals and clinics have been around nearly as long as the VA itself. In 1995, a goal was set to have veterans seen for appointments within 30 days. VA doctors’ and executives’ bonuses are based at least in part on meeting timeliness targets. Many believe this is a key reason that waiting lists were doctored (by being kept on a separate “secret” waiting list, before being moved onto the real, computerized waiting list within 14 days of their scheduled appointment). The scandal, which is believed to have contributed to the deaths of dozens of veterans while they waited for appointments, led to much consternation and a call for significant reform to improve the waiting time of veterans.

It was found that veterans were waiting too long for appointments not only in Phoenix (where the “secret waiting list” scandal was discovered) but at many VA sites around the country. This was determined to have significant (though not always easily quantifiable) impact on patient safety as well as patient services to the large numbers of veterans who were unable to get timely appointments. (Read our previous blog about a veteran who lost much of his nose after waiting more than 2 years for a biopsy.)

In order to lessen the waiting times, $16.3 billion in spending to hire more doctors, open more clinics, and create a program that allows veterans to seek private-sector care was approved July 31, 2014. However, a study by the Associated Press has found that from August 1, 2014 to February 28, 2015, over 890,000 appointments failed to meet the timeliness goal. More than 230,000 appointments were delayed more than 60 days. While the number of vets waiting more than 30 and more than 60 days has stayed about flat, the number of appointments that take more than 90 days has nearly doubled. Some specific problem areas have been identified.

Challenges remain with the “Choice Program”: The Choice Program began to cover non-VA care for eligible veterans November 5, 2014. However, eligibility remains limited to those who have to wait more than 30 days from their “preferred date” or a date medically determined by their doctor or those who are more than 40 miles (straight line) from the nearest VA facility or face an unusual travel burden to access it.   Only some private physicians participate. The program is being expanded so that the 40 miles is based on driving distance rather than a straight line calculation, and telephone lines and other programs are being implemented to assist veterans using the program to seek care.

Medically underserved areas have the worst delays: During the government’s investigation, it was found that many VA facilities have inadequate providers for the number of veterans in their care. These areas tend to be areas that are medically underserved, which compounds the problem because civilian options in the area are also limited, limiting the effectiveness of the program that allows veterans to seek private-sector care. Says Dr. Kevin Dellsperger, chief medical officer at Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa, “Not a lot of medical students want to go work for the VA in a rural community medical clinic.” While 8,000 employees were added to the VA between April and December 2014, it’s hoped that increasing salaries in the underserved areas will attract more providers.

Physical space is also an issue: Any government contracting and building process can be cumbersome, and the VA has been identified as having particular difficulty managing the contracting process. When buildings are (finally) constructed, they’re usually already too small.

Enrollment is increasing: Enrollment in VA programs has been expanding rapidly. From 2002 to 2013, enrollment increased from 6.8 million to 8.9 million and spending increased from $19.9B to $44.8B.   Says Robert McDonald, Secretary of Veterans Affairs, “Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care.” It’s hoped that the increased enrollment is actually a positive, buoyed by the efforts made to increase access and shorten waiting times. “I think what we are seeing is that as we improve access, more veterans are coming, ” says Sloan Gibson, the Deputy Secretary of Veterans Affairs.

It may get worse: “The cost of fulfilling those obligations to our veterans grows and we expect it will continue to grow for the foreseeable future. We know that services and benefits for veterans do not peak until roughly four decades after conflict ends . . . we project the benefits for recent veterans in recent conflicts will peak around 2055,” testified VA Secretary McDonald.

The VA administration is asking for patience. Deputy Secretary Gibson says “We are doing a whole series of things – the right things, I believe – to deal with the immediate issue. But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

To view an overview of these issues in a visual cause-and-effect diagram (or Cause Map), as well as some of the associated solutions, click on “Download PDF” above. To read more about the AP’s analysis, click here.

Root Cause

Prisoner escapes from hospital

By ThinkReliability Staff

A recent prisoner escape from city custody in Virginia was only one of four attempted escapes in the US over 8 days related to seeking medical care.  Examining the cause-and-effect relationships shows what led to the prisoner escape and can provide insight into improvements to reduce the risk of it happening again.  These cause-and-effect relationships can be diagrammed visually in a root cause analysis, or Cause Map.

The analysis begins by capturing the what, when and where of the problem.  In this case, the issue being analyzed is the escape of a prisoner from a public hospital in Alexandria, Virginia March 31, 2015 at about 3:00 a.m.  Along with the where, we capture what was happening at the time.  In this case, the patient was receiving medical care after a suicide attempt.  It’s also helpful to capture any differences.  Differences could be in the location, date, time or task being performed.  In this case, a few things stand out from a summary reading of the media reports available.  First, the city jail prisoner was being treated at a public hospital, and second, one of the guards responsible for the prisoner was taking a bathroom break.

These differences may or may not be causally related to the issue, but provide potential causes to consider. As mentioned, there were four prisoner escapes during a week related to medical care.  On the same day, a New Orleans prisoner escaped from a van transporting prisoners to a hospital.  The previous day, a New Jersey prisoner escaped from a hospital, and a week prior, a West Virginia psychiatric hospital patient facing murder charges escaped.

As physical and procedural security at prisons improve, fewer prisoners are escaping from the facilities themselves.  Many times, being removed for medical care is the best opportunity.  Federal prisons, which provide on-site medical care, have far fewer escapes than other facilities.  From 1999 to 2001, only one of 115,000 federal prisoners escaped.

A single trip for medical treatment itself may not be to blame for the escape attempts, but repeat trips to the same medical facility may increase the risk.  Says Kevin Tamez, inmate advocacy consultant, “Very rarely do these guys go to the hospital for treatment and all of a sudden they decide they’re going to escape.  What happens is, traditionally, inmates go to the hospital for treatment . . . they come back to the facility and they start telling other inmates . . . There is nobody more ingenious than an inmate.  They have nothing to do all day but sit around and think things up. There are ways of minimizing it, but there’s never a way to prevent it.”

Having only one guard instead of two, due to a bathroom break, is problematic for obvious reasons.  It’s far more difficult to overwhelm two guards than one.  “From a safety perspective it’s always good to have two people there,” says Gary Klugiewicz, a consultant/ trainer for law enforcement & correctional officers.  The amount of time the guards were watching this prisoner at the hospital (4 days, for reasons that are unclear) may have also played an impact.  It’s hard to keep your guard up for that amount of time.

The U.S. Marshals, who had responsibility for the prisoner at the time, will be reviewing their procedures to look for opportunities for improvement.  Experts suggest that enlisting hospital security to fill in, rather than leaving just one guard in place, may help.  Because the secure healthcare facilities in federal jails allow so many fewer escapes, using these instead of public hospitals may reduce the risk of escape.  However, there’s still the problem of transporting inmates, which is another high escape potential.

To view the Cause Map of the prisoner’s escape, click on “Download PDF” above.  Or click here to learn more.

Root Cause

Disabled resident dies when caregiver falls asleep

By ThinkReliability Staff

A physically disabled resident in a New York state-run care home required checks every two hours to ensure he was receiving adequate oxygen.  On the night of September 10, 2013, his nurse fell asleep, and he went more than 8 hours without the checks.  During this time, his oxygen level dropped to 40% (anything below 90% is considered dangerous), and he later died of hypoxic brain injury.

Says Patricia Gunning, prosecutor for the New York State (NYS) Justice Center for the Protection of People with Special Needs, “This case serves as a tragic reminder of the serious risk posed by an all too common workforce problem of caregiver fatigue or workers sleeping on shifts.”

Sadly, “all too common” turned out to be all too true.  The NYS Justice Center for the Protection of People with Special Needs was formed in mid-2013, and oversees agencies responsible for more than a million people in state care or state-funded nonprofits.  During its first year, it found 458 reports alleging abuse or neglect that cited a caregiver sleeping on the job.  This included caregivers who slept through a resident’s grand-mal seizure and a resident’s elopement, residents with unattended access to medications and food, and residents who were in a car driven by a caregiver who fell asleep at the wheel.

Even with a seemingly overwhelming problem such as this, progress can be made by looking at the specifics of one case, identifying causes that led to the problem, and developing solutions.  These solutions can then be considered for individual or widespread application.  We will examine the specifics of this case in a Cause Map, or visual root cause analysis, which lays out the cause-and-effect relationships leading to a problem.

The problem being examined is determined by the impact to an organization’s goals.  In this case, the resident safety goal was impacted because of the death of the resident.  The resident services goal was impacted because the resident did not receive adequate oxygen.  The compliance goal is impacted because of the felony charges against the nurse, who was sentenced to 90 days in prison.

Beginning with the most prominent impacted goal – in this case the resident safety goal – and asking “why” questions develop the cause-and-effect relationships that led to that impact.  In this case, the resident died from hypoxic brain injury (per diagnosis), from a lack of oxygen.  Due to the resident’s physical disability, his oxygen delivery equipment was required to be checked every 2 hours around the clock.  On the night of September 10 to September 11, more than 8 hours passed between checks, at which point the patient was found unresponsive.  (He died two weeks later.)

The resident’s oxygen delivery was not checked for more than 8 hours (as opposed to the required two) because the caregiver on duty had fallen asleep.  Testimony from the nurse in question as well as others from the facility describing sleeping on overnight shifts as a common occurrence.  Later research from the NYS Justice Center for the Protection of People with Special Needs found that many incidents involving caregiver sleeping on duty involved staff working extended or otherwise non-traditional work shifts.  The nurse who fell asleep on duty worked 12-hour night shifts at a site where many signed up for overtime and just barely passed duty hour requirements.

In response to the numerous caregiver sleeping events it discovered, the NYS Justice Center for the Protection of People with Special Needs has provided a toolkit aimed to protect people with special needs from caregiver fatigue.  The Center recommends that care provider agencies implement & regularly review policies meant to deter and detect sleeping on the job, establish contingency plans to relieve staff found unfit for duty, and provide assistance to residents in calling for help if caregiver is unresponsive.  Due to the myriad issues associated with caregiver fatigue, the American Nurses Association (ANA) continues to fight to reduce nurse fatigue, and possible harm to patients.

To see a one-page PDF with an overview of the investigation related to the resident lack of oxygen due to caregiver sleeping, click on “Download PDF” above.  Or, click here to learn more.

Root Cause

What Caused an HIV Outbreak in Rural Indiana?

By Kim Smiley

A public health emergency has been declared after 79 cases of HIV were confirmed in rural Indiana, the worst outbreak of HIV the state has ever seen.  Individuals potentially at risk have been encouraged to get tested and the number of cases is expected to rise as more cases are identified. The epidemic has been tied to intravenous drug use, although other risky behaviors may also have spread the disease.

In order to effectively fight this HIV epidemic and hopefully reduce the risk of outbreaks in the future, the factors that have led to these HIV cases needs to be understood. This region has been struggling with the use of Opana, a powerful opioid painkiller, for years.  Opana is commonly injected and health officials believe that the use of dirty needles has been the primary driver of HIV infections although unprotected sex was also a potential pathway for infection for some.  Needle exchange programs are illegal in Indiana and access to clean needles is limited so needles are being shared.  In an environment where needle sharing is common, it takes only one individual infected with HIV to rapidly spread the virus to many other drug users.

HIV is also more likely to be spread if infected individuals are unaware that they are infected and are not being treated.   Identifying an individual who has contracted HIV as early as possible and providing treatment helps prevent the disease from spreading because an HIV-positive person who receives sustained treatment is drastically less infectious, even if they continue to engage in high risk behaviors. Access to healthcare and HIV testing is limited in this region where many residents are uninsured and may lack transportation. Heroin use has long been tied to HIV, but users of Opana (a licensed pharmaceutical) may not have been fully aware of the potential risk from sharing needles.

Now that the HIV epidemic has been identified, healthcare officials are working to reduce the risk of more infections by providing testing and treatment.  One physician is even driving door to door, offering free HIV testing and trying to educate residents on drug addiction and HIV treatment.  Austin, Indiana has established its first ever HIV clinic to provide testing, counseling and treatment.  Targeted resources to help educate residents on drug use and to assist addicts seeking to get clean are also being provided.  The governor of Indiana has approved a short term needle exchange program.  Indiana has also created a public awareness campaign to help inform people about the risks of intravenous drug use.  Drug addiction is a notoriously difficult problem to battle, but the additional resources should help reduce the rate of future HIV cases.

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

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

65 surgeries required for boy who swallowed button battery

By ThinkReliability Staff

As you can imagine, as someone who regularly analyzes and reports on disasters of every kind, my mind is never far from things that could harm my children. Though the types of events I typically include are well-publicized, the real dangers for children tend to be things closer to home, that one might reasonably consider harmless.

Even after our blog about the dangers of children swallowing batteries (regarding a study that said a child in the US visits an emergency room every 3 hours for issues involving a battery and that 84% of these are button batteries), I didn’t really get it. Sure, swallowing anything is bad, and batteries have nasty chemicals in them. But it wasn’t until I read the story of Emmett Rauch that I really got how bad these issues could be.

When Emmett was one, he swallowed a button battery. His parents could tell that something wasn’t right, and Emmett was diagnosed with a cold, then croup. Luckily at a pediatrician visit 3 days after he swallowed the battery, the pediatrician had second thoughts and sent Emmett to the ER for an x-ray. Once the button battery was discovered lodged in his esophagus, the rush to treat him began. Emmett would receive 65 surgeries over the next four-and-a-half years to rebuild his esophagus and vocal chords.

Amazingly, Emmett is a survivor. He’s one of the lucky ones. There have been 15 deaths associated with small batteries over the last 6 years. Emmett’s mother, Karla Rauch, is now an activist for button battery ingestion awareness. The issues resulting in deaths and injuries to children (primarily under the age of 5) regarding button batteries are as follows:

Chemical reaction caused by batteries in the esophagus: Batteries (even “dead” ones) contain chemicals that create current. The moistness of the esophagus can cause a chemical reaction that can burn holes in the tissue.

Accessibility of button batteries: Kids like shiny things and they like to put things in their mouth. The first line of defense is preventing access to small batteries. Here’s how:

– Keep loose batteries out of reach of children

– Ensure battery compartments on products are secured

– Buy products with battery compartments that require a tool to open if possible

– Use duct tape to secure products with batteries that don’t require a tool

Difficulty of diagnosis – at home: Because the batteries are so small, kids will likely still be able to breathe after swallowing them, limiting parent’s ability to figure out that they’ve swallowed something they shouldn’t. Because of the ubiquity of small batteries, parents may not realize they’re missing.

Difficulty of diagnosis – at the hospital: An x-ray is required to determine that a child has swallowed a battery. An x-ray may not be called for if a doctor thinks (as is common) that the coughing or apparent throat damage is due to another sickness. Even though button batteries have been around for a while, they’re still not a risk that is very apparent to most people. So, if you think there is a possibility your child may have swallowed a battery, act quickly:

– Seek immediate medical attention if you believe a battery has been swallowed

– Do not let the child eat or drink

– Do not induce vomiting

– Tell the medical staff it may be a small battery

– If possible, provide information on the battery

To view an overview of this issue and solutions, please click on “Download PDF” above. Thanks to Karla Rauch for sharing her story. To learn more, see www.emmettsfight.com.