Tag Archives: Root Cause Analysis

Root Cause

Patient Gets MRI (and a Diagnosis) Only After 24 Visits to 13 Doctors

By ThinkReliability Staff

In a tragic case of incorrect diagnosis, a 16-year-old patient died January 24, 2013, eleven months after being diagnosed with “migraines”.  In fact, the patient had a rare brain tumor (known as a disseminated oligodendroglioma-like leptomeningeal tumor).  She died eight days after receiving an MRI that finally properly diagnosed the causes of her headaches, numbness, nausea and eyesight problems.

It’s unclear if earlier diagnosis would have saved the life of the patient.  Though the prognosis is poor for a leptomeningeal tumor, a oligodendroglioma that is treated before it is disseminated gives a long-term survival chance to 80-100%.  The tumor had disseminated once it was found on the MRI, eleven months after the patient was diagnosed with migraines.  However, even if her prognosis was poor, the patient could have spent the last eleven months of her short life enjoying time with her family and friends, instead of making 24 trips to 13 different doctors and, in one particularly devastating appointment, being accused of “putting the symptoms on”.

Although the coroner at the inquest said there was no need to make a formal recommendation for changes at the hospital that failed to diagnose the patient, a spokesperson for that hospital said “In the next few weeks, many of the clinicians who looked after Natasha will be meeting to discuss this sad case and ensure that any opportunities for learning are not missed.”

It is hoped that these opportunities for learning can reduce the possibility of another patient suffering as this patient did, due to a misdiagnosis.  Misdiagnosis is a common source of medical error.  According to an article by Michael Astion, MD, PhD, “Available data suggests that misdiagnoses occur in 15% or more of clinical cases, but overall there is very limited data on the frequency of misdiagnosis in medicine.”  Especially in rare clinical cases such as this one, sharing details of the disease and diagnosis may help other clinicians in the same position.

In order to effectively determine lessons learned and improvements that can be made, the details of a case need to be presented clearly and concisely.  I’ve put together the details of the case in a Cause Map, which uses cause-and-effect to demonstrate the linkage of the issues that led to the tragedy discussed here.

In a blog discussing the cases and possible responses, Suzanne Leigh suggests that if an MRI was denied, other cheaper alternatives, such as a CT scan, be considered.  She also suggests a much more thorough review to “ensure that in the future, scans are  not withheld from patients with potentially life-threatening conditions”  and that the hospital involved should “study the flaws in the system and human errors that led to the failure of 13 doctors to order a diagnostic MRI that would have resulted in emergency treatment earlier in the disease’s progression”.  Given the tragedy of this case, the suggestions seem far more appropriate than the treatment of the patient over the last year of her life.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause

FDA Proposes Restrictions that Would Essentially Ban the Use of Trans Fats

By Kim Smiley

On November 7, 2013, the US Food and Drug Administration (FDA) proposed reclassifying trans fats so that they would no longer be “generally recognized as safe.”  This move would essentially eliminate the use of trans fats because companies would need to prove that they are harmless before adding any to food products.  This hurdle would likely be impossible to jump since current research shows that trans fats are the least healthy fat and contribute significantly to heart disease in the US.  In fact, it’s estimated that the increased restrictions on trans fat proposed by the FDA would prevent 20,000 heart attacks and 7,000 deaths from heart disease each year.

Trans fats are an especially dangerous form of fat because they raise the levels of “bad” cholesterol, while also lowering the “good” cholesterol.  This double whammy significantly increases the likelihood of heart disease. One of the interesting twists in the history of trans fat is that its rise to popularity was partly fueled by a belief that it was a healthy alternative because it was manufactured from plants, unlike traditional saturated animal fat like butter or lard.    Trans fats were also cheaper, increased product shelf life and were kosher.   From the 1950s until recently, trans fats were widely used in a variety of processed foods.

Things began to change in 2003 as more and more research showed that trans fats were less healthy than initially thought and the FDA added a requirement that artificial trans fats be listed separately on food labels.  Manufacturers begin to shift away from the use of trans fats after their visibility was increased and the public became more aware of the dangers of trans fat.  The shift away from the use of Trans fats has already dramatically impacted the American diet.  In 2006, Americans consumed an average of 4.6 grams of trans fats daily which decreased to about 1 gram in 2012.  Food manufacturers are not predicted to fight the new FDA proposal too aggressively since so many have already voluntarily reduced the use of trans fats.  Additionally, no company wants to be associated with the negative publicity surrounding trans fats.

The impacts of trans fats can be analyzed by building a Cause Map, a visual root cause analysis, which intuitively lays out causes that contribute to an issue to visually show the cause-and-effect relationships.  A Cause Map is built by determining how the overall goals are impacted by issues and then asking “why” questions to determine all the causes that contributed to the problem.  Click on “Download PDF” above to view a high level Cause Map of this issue and view a completed Outline.

Root Cause

Analysis of Causes of Patient Data Breaches

By ThinkReliability Staff

When dealing with a seemingly overwhelming problem, care should be taken to ensure that resources are used most effectively by addressing the causes that have the biggest impact on the issue.  Take the case of HIPAA breaches of medical records.  Since February of 2010, 26.8 million individuals in the United States have been impacted by a data breach.  There are multiple potential causes that could result in these data breaches. So, where should efforts be directed to be most effective?

Looking at actual events and determining the probability of different types of failure can better direct your solutions, even if your organization hasn’t personally experienced a data breach.  We do this in a proactive Cause Map, which looks at potential causes and – when data is available – determines the relative probability of each contributing cause.  Luckily for us, this analysis has already been performed for data breaches reported to the HHS since February 2010.  We will use here breach analysis and graphs created by medical software research resource Software Advice in a recent report on the subject.

The biggest cause of patient data record breaches is theft.  Theft accounts for at least 48% of breaches.  (There were also incidents described as combination, other or unknown, which may also involve theft.)   As an example, a health insurance provider lost nine server drives that included information for 1.9 million people, two years after a portable disk drive was stolen that included personal data for 1.5 million members.  (View our analysis of patient data breaches caused by theft in our previous blog.)

The next largest cause of patient data breaches is unauthorized access.  Unauthorized access is the cause of 18% of data breaches.  These types of breaches have the potential to result in employee action in addition to the other goals that are impacted.  These events may involve outside contractors, or “Business Associates” (BAs).  BAs are involved in 22% of incidents, but account for 48% of impacted individuals due to data loss.  An example of a patient data breach caused by an outside contractor is the case involving records of 20,000 patients, which were posted online by a contractor.  (View our analysis of this data breach in our previous blog.)

Loss accounts for 11% of patient data breaches.  This includes the largest patient data breach from the time period covered, when a TRICARE BA (contractor) lost backup tapes, impacting the records of nearly 5 million patients.   Improper disposal, such as when a shredding company abandoned the records of 277,000 patients in a public park, accounts for 5%.  Hacking also occurred in 6% of breaches, such as when the servers at the Utah Department of Health were broke into and records for almost 800,000 people were stolen. (Remaining events are classified as a combination of the above, other, or unknown.)

The HIPAA Omnibus Rule clarified liability for Business Associates and subcontractors, which should serve to reduce their involvement in data breaches.  But for the events that don’t involve outside parties, how can these events be reduced?

Focusing on two of the most likely causes of breach – theft and loss – encryption can reduce the risk that data can be accessed if physical devices are stolen.  Laptops account for 22% of breaches, and other portable devices account for 12%.  However, encryption won’t help with paper records, which account for 23% of data breaches.  In these cases, limit to access of records and prevention by removing records from the storage site can help, as can moving from paper records to electronic health records, which accounted for only 2% of  data breaches.  However, the storage devices used for electronic health records, including laptops, as discussed above, network servers (10%), computer (13%) are more likely to be involved. Because physical storage devices account for so many data breaches, whether or not electronic records are being used, cloud storage is worth consideration.  Although hacking is still a concern, remember that it accounts for just 6% of breaches – as opposed to theft and loss, which make up nearly 60% of breaches.

To view the proactive analysis/ Cause Map of these data breaches, please click “Download PDF” above.  Or click here to read more.

Root Cause

United Nations Sued for Role In Haitian Cholera Epidemic

By Kim Smiley

A class action law suit has been filed against the United Nations (U.N.) on behalf of Haitian families afflicted by the cholera epidemic that has been raging since 2010.  Many believe that cholera was inadvertently brought to Haiti by U.N. peacekeeping forces.

Some of the basic facts are still debated, but one that is known is that Haiti is experiencing the worst cholera epidemic in modern history with thousands of new cases each month. Nearly 7 percent of the Haitian population has had cholera since 2010.  It’s estimated that around 8,400 people have died of cholera and more than 685,000 have been sickened by the disease.

So why is the U.N. being blamed for this epidemic? A Cause Map, or visual root cause analysis, can be used to explain what many believe occurred.  All causes that contributed to an issue are captured on the Cause Map, which illustrates the cause-and-effect relationships between them.  In this case, people became infected with cholera after drinking contaminated river water.  Many believe that the river was contaminated when sewage leaked from a U.N. camp near the river with inadequate sanitation facilities.  U.N. peacekeepers from Nepal were stationed at the camp and cholera, specifically a nearly identical strain of cholera, was present in Nepal at the time.  It’s assumed that at least one person in the camp had cholera and dangerous wastes managed to contaminate the river. The cholera epidemic seems to be a deadly case of unintended consequences that occurred when the U.N. attempted to aid Haiti following a devastating earthquake.

Once cholera got a foothold in Haiti, the epidemic exploded.  The population had little immunity to the disease because a case hadn’t been seen in Haiti in over a century prior to 2010.  Haiti lacked the sanitation and medical facilities to quickly contain a cholera epidemic.  People continued to drink water from the river because there weren’t many other options. The country had also suffered major damage from the 7.0 magnitude earthquake that hit on January 12, 2010.  Medical facilities, transport facilities, communication systems and all the things a country needs to battle an epidemic had been significantly impacted by the earthquake.  Basically, it was a perfect recipe for a disaster.   A sick U.N. soldier may have brought cholera to Haiti, but the conditions in the country amplified the situation.

The world is still struggling to understand the cholera epidemic and determine what lessons learned should be applied going forward.  Clearly there is something to learn about the need for sufficient sanitation so that illness doesn’t spread unnecessarily.  The U.N. may potentially want to screen troops more closely before stationing them on foreign soil or implement other changes to help prevent anything like this from occurring in the future.  It’s also a powerful reminder to be aware and on the lookout for unintended consequences whenever a solution is implemented.  For example, the U.N has always had legal immunity, but some believe that may change as a result of the cholera lawsuit.   It’s impossible to predict if a verdict against the U.N. would impact future U.N. aid efforts, but it’s easy to imagine that it could have damping effect on their efforts, causing a whole other wave of unintended consequences to occur.

To view a high level Cause Map of the cholera epidemic in Haiti, click on “Download PDF” above.

Root Cause

National Effort Improves Cardiac Arrest Survival Rates

By ThinkReliability Staff

October is Sudden Cardiac Arrest (SCA) Awareness Month.  In Northern America, more than 300,000 people are affected every year by out-of-hospital SCA, which occurs when the heart no longer beats properly.  According to the American Heart Association, about 92% of SCA victims die before reaching the hospital.

Survivability of SCA is dependent on the length of time between SCA and chest compressions that allow blood flow to the heart and brain.  This can be accomplished by non-medical personnel using Cardiopulmonary Resuscitation (CPR), known as “bystander CPR”, which can provide lifesaving treatment for a victim of SCA until medical personnel arrive.

In Denmark, the rate of patients who received bystander CPR in 2001 was 21.1%.  The country embarked on a national initiative to improve SCA survivability.  This initiative included increased training of residents as early as elementary school.  Instructional kits were provided, and learning CPR was required in order to receive a driver’s license.  The percent of patients who received bystander CPR increased from 2001 to 2010 to 44.9%.

In addition to the increased education of the general population about CPR, changes were made to improve care provided after SCA by hospitals and emergency medical services.  According to a study in the Journal of the American Medical Association, these changes together have improved the survivability of all stages after SCA.  From 2001 to 2010 in Denmark, cardiac arrest patients arriving at a hospital alive increased from 7.9% to 21.8%.  In addition, 30-day and 1-year survival also increased, from 3.5% to 10.8% and 2.9% to 10.2%, respectively.

Denmark’s initiative hopes to lessen the reluctance bystanders may have to perform CPR due to lack of training.  In addition, the American Heart Association recommended in 2008 that laypersons perform compression-only CPR (no breaths) if they are unable or unwilling to provide rescue breaths.  This may have also decreased the reluctance of bystanders to perform CPR due to concerns about spread of disease, or feeling uncomfortable giving rescue breaths.

Providing additional training to emergency medicine providers can also improve survivability.  Another recent study by the University of Arizona has found that improving the quality and effectiveness of CPR performed by emergency medicine providers improved survival rates.  In the study, rescuers were provided real-time feedback as to the quality of the CPR being provided, as well as training that emphasized a team approach.  Before these interventions, 26% of SCA victims survived to hospital discharge.  After the interventions, 56% of victims survived to discharge.

Although CPR dates back to 1740, improvements in availability and quality are still being found that can increase survivability of SCA victims.  Because of the importance in quick and effective action, the importance of action by non-medically-trained bystanders to the survival rate after SCA provides strong support for layperson CPR training.

To view the Outline and Cause Map including the cause-and-effect of the improvements to survival rate in Denmark as a result of interventions and improvements, please click “Download PDF” above.

Root Cause

RISK: Vaccines vs. Disease

By ThinkReliability Staff

Although endemic transmission of measles has been considered “interrupted by vaccination” in the United States, a recent measles outbreak has brought to the forefront the risks of not getting vaccinated.  A member of a church in Texas, who had not received the full measles vaccination, traveled to Indonesia, an area where measles is still endemic.  The disease, which is easily spread in close contact, then infected at least 20 other members of his church, which has concerns about the risks of vaccination, especially bundled vaccinations like the MMR (measles/ mumps/ rubella) vaccine.

In recent years, people have been increasingly concerned about the risks of vaccination.  One of the main concerns with the MMR vaccine is its purported link to autism (which was first mentioned in a 1998 study that has been mostly discredited).  There are, of course, risks to vaccination for any disease.  According to the CDC, risks from the MMR vaccine include mild problems, such as fever (up to 1 person out of 6), mild rash (up to 1 person out of 20) and very rare severe problems, such as allergic reactions (which occur in less than 1 out of a million doses).

However, as the CDC notes “The risk of the MMR vaccine causing serious harm, or death, is extremely small.  Getting the MMR vaccine is much safer than getting measles, mumps or rubella.”  This brings us to the other side of the equation.  People who do not get vaccinated for these diseases face the risks of getting the disease.  According to Dr. Paul Offit, Chief of the Division of Infectious Diseases and Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, “There are only two ways you can develop specific immunity, either be infected by the natural virus or be immunized.  A choice not to get a vaccine is not a risk-free choice, It’s a choice to take a different and more serious risk.”

Because transmission of measles had been considered effectively stopped in the US, not vaccinating may have seemed like a minor risk.  After all, there are some people who cannot receive the vaccine.  This includes young children, pregnant women, and those who may be suffering from other health concerns.  These people have generally been protected by “herd immunity”.   This refers to the unlikelihood of getting measles when a very high percentage of the population is vaccinated against it.

However, in recent years, the number of people choosing not to get vaccinated has been increasing.  Sometimes these people are clustered geographically, such as within a church that has expressed its concerns about vaccinations (as in the recent outbreak in Texas).  When unvaccinated persons travel to an area that has not made as much progress towards eradicating disease, the likelihood of disease spreading is much higher.

This is true for other diseases as well.  The Texas Department of State Health Services has recently released a health alert regarding vaccination against pertussis (whooping cough) after more than 2,000 cases this year, including two deaths of infants too young to be vaccinated..  Says Dr. Lisa Cornelius, the Department’s infectious diseases medical officer, “This is extremely concerning.  If cases continue to be diagnosed at the current rate, we will see the most Texas cases since the 1950s.”

Although the potential risk of a vaccine may seem frightening, it is important to ensure that everyone in your family is fully vaccinated.  Not only will this provide the best protection for each of you, it will also provide protection to those members of your community who cannot be vaccinated, and limit the spread of these diseases.  Some communities are experiencing this the hard way. The Texas church involved in the outbreak has begun offering vaccination clinics for its members to attempt and stop the outbreak and protect against another one.

You can view the Outline and Cause Map discussing this issue by clicking “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.

Root Cause

Adult Dose of Heparin Delivered to Premature Infants

By ThinkReliability Staff

On September 16, 2006 6 premature newborns in Indianapolis were given adult doses of the blood thinner heparin, used to prevent blood clots that could clog intravenous (IV) tubes.  Adult doses are 1000x more concentrated than infant doses.  Three of the babies died and the other three were in critical condition.  In 2007, in Los Angeles, an overdose was given to three more babies due to the same error.  Luckily none of those babies died.  (Up to 17 babies in Texas also received heparin overdoses in 2008, but these were caused by a mixing error at the hospital pharmacy.)

We can examine this issue in a visual root cause analysis, or Cause Map.  Fully investigating the errors that occurred for these overdoses to happen can lead us to solutions to increase healthcare reliability by decreasing the risk of the same situation recurring.

We begin with the outline, where we capture the what, when and where of the incident, as well as the impact to the organization’s goals.  These medication overdoses impacted the patient safety goal because they resulted in fatalities and serious injury to the babies who received the medications.  Additionally, employees involved in the issue can be affected as a second victim.  Death or serious disability due to a medication error is a “Never Event“, which is an impact to the organization’s compliance goals.  Patient services are impacted due to the incorrect drug dose delivery.

Once we’ve determined the impacts to the goals, we can ask “Why” questions to determine the cause-and-effect relationships that led to the incident.  In this case, 5 opportunities for double-checking the dosage were missed.  The wrong dosage was missed as 1) the bottle was removed from the pharmacy, 2) the bottle was placed in the cabinet, 3) the bottle remained in the cabinet, 4) the bottle was taken from the cabinet, and 5) the drug was administered to the babies.  Some of the reasons that it was missed: there was no effective double check by another staff member, there was no check by a computer and of course due to human error, which was aided by the issue that the adult dosage bottle and the infant dosage bottle looked practically identical (this has since been remedied).

An article in The Journal of Pediatric Pharmacology and Therapeutics states, “As frequently occurs, all of these heparin-associated medication errors happened when a number of system failures occurred simultaneously. System failures included: 1) failure to carefully and accurately read the label on the medication vial prior to administering the drug to the patient; 2) inaccurate filling of automated drug-dispensing cabinets; 3) non-distinct “look-alike” labels on the heparin vials; 4) similar size of the heparin vials as both were 1-mL vials; and 5) “factor of ten” dosing errors.”

Many solutions to this type of error (such as requiring double checks by staff members and using a computerized prescription dispensation system) were suggested as a result of this and other heparin overdoses over the past several years and are already being implemented at hospitals across the nation.

To view the Outline, Cause Map and potential solutions please click “Download PDF” above.  Or click here to read more.

Root Cause

Woman Dies After Neck Trapped Between Mattress and Bed Rail

By ThinkReliability Staff

On January 26, 2013, a nursing home resident died of positional asphyxiation after her neck became trapped between her bed’s mattress and a bed rail.  The nursing home was cited for neglect by the state for not evaluating whether or not the use of a bed rail is appropriate.

The cause-and-effect relationships that led to the resident’s death can be diagrammed in a Cause Map, or visual root cause analysis.  This allows all the issues related to the incident to be examined so that as many potential solutions as possible can be considered, increasing healthcare reliability.

The first step in the Cause Mapping method is to capture the what, when, and where of the incident, as well as the impacts to the organization’s goals.  A nursing home’s goals include ensuring residents’ safety,  employees’ safety, residents’ quality of life, and compliance with regulatory and other accrediting agencies.  In this case, the resident safety goal was impacted because of the resident death.  The resident quality of life was impacted because there was no assessment performed to ensure the use of bed rails was appropriate.  Because that assessment was not performed, the facility was fined by the state Health Department.  Additionally, the compliance goal was impacted because both the Centers for Medicare and Medicaid (CMS) and The Joint Commission prohibit the use of bed rails when used as restraints.  CMS also will not reimburse for treatment for injuries related to the use of bed rails.

Beginning with an impacted goal, asking “Why” questions aids in developing the cause-and-effect relationships that resulted in the impact to the goal.  In this case, the resident death was caused by positional asphyxiation because the resident’s neck was caught between her bed rail and mattress.  The asphyxiation also resulted from the resident not being found immediately.  In this case, there were forty minutes between the last nursing check and when the resident was discovered.

The resident’s neck was caught because she was unable to free herself due to limited mobility and dementia and the use of bed rails.  In this case, as previously noted, an assessment to determine whether the use of the bed rail was appropriate had not been performed.   Presumably the bed rail was used because of the resident’s history of falls. Despite research that the risks outweigh the benefits when using bed rails as restraints (as opposed to mobility aids for residents who are cognitively and physically able), the FDA has stopped short of requiring a safety label on bed rails.

The nursing home involved in this incident has provided an approved plan to reduce the risks of this type of incident recurring.  Beyond that particular facility, states Minnesota Commissioner of Health Dr. Ed Ehlinger,  “As a result of this death, we want all health settings where bed rails are used to take immediate steps to make sure they are following the correct guidelines around bed rails, grab bars and other devices.”

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more about the use of bed rails and associated risks.

Root Cause

New Limits Proposed for Arsenic in Apple Juice

By Kim Smiley

The FDA recently proposed a new limit for the amount of arsenic allowed in apple juice.  The proposed limit would match what has already been established for bottled water.  This marks the first time that the FDA has established an arsenic limit for food or drinks other than water.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map lays out the causes that contribute to an issue in an intuitive, visual format so that the cause-and-effect relationships are obvious.  The first step of the process is to fill in an Outline with the basic background information for an issue.  The Outline also documents the impacts that the issue is having on the organizational goals so that the full effect of the issue can be clearly understood.  In this example, the concern that consumers may be exposed to arsenic, a known carcinogen, is an impact to the safety goal.  The media hype surrounding this issue is also important to consider because consumer concern could impact sales.

After the Outline is complete, the next step is to ask “why” questions and use the answers to build the Cause Map.  So why is there arsenic in apple juice?  Arsenic is a naturally occurring substance that is found in the environment.  There are also places that have been contaminated by arsenic, primarily the result of arsenic-based pesticides.  Use of arsenic-based pesticides in the US ended by 1970, but parts of the world still use them.

To understand this issue, it’s also important to understand the public relationships portion of  the puzzle. The concern over arsenic in apple juice exploded after the issue was featured on the “The Dr. Oz Show” in 2011.  Outcry after the segment was well covered by major media outlets and the issue has repeatedly made headlines over the past two years. Consumer Reports has also issued a report about samples of apple juice that test above the limit for drinking water.  None of this can possibly be good for the apple juice business.

The final step of the Cause Mapping process is to use the Cause Map to develop solutions.  A limit for arsenic in apple juice should go a long way to easing concerns if it is established.  The proposal is to set the limit for arsenic in apple juice to match that for drinking water, which should be conservative since consistent consumption of more apple juice than water seems unlikely.   Producers of apple juice that is found to contain arsenic above the limit could face legal action and the juice could be removed from the market.  How much the new limit will actually impact the products on the shelf is unclear because different sources have reported widely different sample results, but at least action could be taken if any juice is found to have arsenic levels above the limit.