Tag Archives: Process Map

Root Cause

Helping the Blind See

By ThinkReliability Staff

Retinitis pigmentosa is an eye disease which results in the degeneration of photoreceptor cells in the retina.  Although it is uncommon, it is estimated that 100,000 Americans suffer from it, but a new device may be able to help them.

In normal sight, the light from a signal enters the eye and contacts photoreceptor cells in the retina.  The photoreceptor cells generate electrical impulses, which are sent to the brain by the optic nerve, allowing the vision to be interpreted by the brain.  In retinitis pigmentosa, their photoreceptor cells deteriorate, short-circuiting the vision process, eventually to the point where there is no vision at all.

To assist in our understanding of the normal vision process, and the problems with it resulting from retinitis pigmentosa, we can use a process map, or a visual step by step diagramming of any process that is examined as part of a root cause analysis.  Although in this case the process is a biological one, diagramming any process that is not producing the desired results can provide important information to develop solutions that allow the process to  again provide the desired results.

With advanced retinitis pigmentosa, all vision can be lost.   Although researchers continue to attempt to discover ways to restore as much vision as possible, any improvement can improve quality of life.  A device called the Argus II, which was approved by the FDA for use in the US on February 14, 2013, aims to help those with retinitis pigmentosa – and possibly in the future those who are blind from macular degeneration.  The device was approved in Europe in 2011 for any type of outer retinal degeneration.

The device uses a camera, video process and electrodes which do the processing work normally performed by photoreceptor cells and the optic nerve.  The electrode provides a pixelized light/dark pattern to the brain, which can allow sufferers to  see outlines and differentiate between light and dark.  Again, a process map can help demonstrate how the device works to bypass the normal vision process.

To view a process map of normal vision, and partial vision provided by the Argus II device, please click “Download PDF” above.  Or click here to read more.

Root Cause

Interpretation of Electronic Fetal Heart Rate Monitoring

By ThinkReliability Staff

Electronic fetal heart rate monitoring (EFM) is used to determine fetal distress.  When fetal distress is indicated, intervention and/or early delivery are generally performed.  Because of this, EFM is performed frequently, even in low risk births.  However, EFM has a high rate of false positives, resulting in unnecessary surgical intervention, which can impact both patient safety and an organization’s goals, especially as the rate of cesarean sections continue to increase.  One of the causes for these high rates of false positives is the variable and inconsistent interpretation of EFM data.  This is in itself an impact to the patient services goal.

This produces a highly simplified version of the Cause Map, but leads to a cause that has significant opportunity to provide improved results.  Specifically, the cause of “variable and inconsistent interpretation” suggests that guidance for more consistent interpretation may aid in reducing unnecessary surgical intervention due to false positives from EFM.

With guidance provided from the American Family Physician, we can create a process map to aid in the use of EFM.  A process map shows the steps and decision trees involved in a process, attempting to guide practitioners towards accepted best practices.

EFM is used continuously for high risk patients and intermittently for low risk patients  unless abnormalities occur.  There are three types of patterns produced by EFM: reassuring, non-reassuring, and ominous.  (Definitions for these patterns, as well as high risk patients are also from the American Family Physician).  Reassuring patterns generally are found to correlate with fetal health, and indicate that the delivery can continue.  Ominous patterns should lead to evaluation for immediate delivery.  Non-reassuring patterns are found between the two – and so lead to the most difficulty in interpretation.  Specific steps are outlined to be taken in the case of non-reassuring patterns which attempt to normalize the pattern.  Additionally, specific tests are recommended to attempt to determine the cause.  If the cause can be determined and corrected, continuous monitoring should accompany an attempt to continue the delivery.

If the pattern is not normalized, evaluation for immediate delivery should occur.  There is no decision tree at this stage  because the decision on whether (and how quickly) to perform delivery must be determined based on the patient’s specific state, based on the knowledge of the practitioner.  Although some steps remain subjective, attempting to fit those that are not into a process map can improve the odds for everyone.

Root Cause Analysis

Number of Gout Cases Continues to Increase

By Kim Smiley

Gout was historically known as “the disease of kings” or “rich man’s disease” and has long been associated with rich food and excessive alcohol, but recently gout has become a common problem across all socio-economic classes.  More than six million adults in the US have gout and the number will likely keep rising in the future.

Gout occurs when there are high levels of uric acid in the blood stream.  Excessive uric acid forms crystals that collect in joints and soft tissues, causing acute pain and inflammation.  Uric acid is produced when the body processes purines.  Purines are found naturally within the body and are also found in many types of food, including meat (especially organ meat), anchovies, herring, asparagus and mushrooms.

Why are more people suffering from gout? This issue can be investigated by creating a Cause Map and performing a root cause analysis to determine what causes contribute to the problem. (Click on the “Download PDF” button above to view a high level Cause Map of this issue.)

Digging through some of the data available, it becomes clear that the modern diet is one cause, but there are a number of other causes that contribute to gout including higher life expectancy, higher weights, and modern medications.  Risk of gout is also higher for people who suffer from a number of illnesses, including hypertension, diabetes, high cholesterol and congestive heart failure; all diseases which are more common now than they were in the past thanks to advances in modern medicine and increased life expectancy.  Obesity also makes gout more likely and today’s population is heavier on average.  There are also several medications that have been shown to increase the risk of gout, including medicines commonly used to treat high blood pressure and low-dose aspirin.

Gout has typically been considered a man’s disease, but now more women are suffering from it. Prior to menopause, woman naturally have lower levels of uric acid in their blood, but as women live longer more cases of gout are developing in women.

Looking at the risk factors associated with gout, it’s clear why more and more people are suffering from it.  Some risk factors can’t be changed, such as gender or age, but staying healthy overall can reduce the likelihood of suffering from gout.

Root Cause Analysis

Why Potassium Iodide?

By Kim Smiley

In addition to evacuating the people near the nuclear plants in crisis, the Japanese government has distributed potassium iodide.  There has also been a run on potassium iodide on the West Coast of the United States.

Why?

Why would pills protect against radiation?  The first part of the answer lies in the thyroid gland.  The thyroid contains some of the only cells in the body that can absorb iodine.  The thyroid needs iodine in order to produce thyroid hormones which are used by nearly every cell in the body and help regulate important functions such as metabolism.  The second part of the answer is that iodine-131 is a common isotope produced by the fission of uranium atoms during the operation of nuclear reactors.  When fission products are released into the environment and consumed by humans, the thyroid can absorb radioactive iodine, just like it absorbs stable iodine.  Exposure from radioactive iodine can lead to thyroid cancer.

When exposure to radiation is possible, potassium iodide is used because the thyroid has a limit to how much iodine it needs.  If the thyroid has been flooded by stable iodine, it decreases the chance that radioactive iodine will be absorbed.  Any unneeded iodine should be passed through the body relatively quickly, limiting the amount of exposure to the radiation emitted by the iodine-131.

History has shown us that the threat of thyroid cancer is very real following a nuclear reactor accident.  There has been an epidemic of thyroid cancer in the area affected by the Chernobyl accident in 1986.  Experts believe that distribution of iodide potassium could have largely prevented this long term health consequence.  Additionally, the majority of iodine exposure came from drinking milk produced by cows living in the area contaminated by the accident.  If people had avoided drinking contaminated milk in the months following the accident, the effects of radioactive iodine would have greatly been diminished.  Another possible solution that could be applied to help prevent thyroid cancer following a reactor accident would be to test all food and drink for contamination.

There are a few other important facts to consider about potassium iodide.  It is not recommend for low levels of radiation.  The U.S. Nuclear Regulatory Committee has stated that very low levels of radiation may reach the United Stations, but that the amount is well below any harmful limit.  Officials have repeatedly stated that there while use of the potassium iodide is an appropriate precaution for individuals near the accident site in Japan, there is no need for people within the US to take potassium iodide to protect against the effects of radiation.  There are also a number of unpleasant side effects associated with potassium iodide and it is recommended that you speak to your doctor before taking the supplement.

Click on the “Download PDF” button above to view a Process Map of how the body absorbs iodine and a high level Cause Map of the thyroid epidemic following Chernobyl.