Tag Archives: solutions

Root Cause

Glitches with Federal Health Care Exchange Website Cause Concern

By ThinkReliability Staff

The website to allow individuals to sign up for the federal Health Care Exchange created as part of the Affordable Care Act opened at midnight on October 1, 2013.  Delays and glitches with the site itself caused difficulties for many trying to enroll.  Three million visitors are said to have visited the site between midnight and 4 p.m. on opening day, though the numbers of how many were actually able to enroll will not be released until November.

This creates a problem not only from a customer service perspective (though that is certainly an important impact to the federal government’s goals of trying to create a consumer-friendly website), but also with regard to the mission of providing affordable healthcare to the population and the labor and time required by federal workers for its success.  Because the cost for healthcare is more for older, sicker parts of the population, more younger, healthier people will need to sign up for the exchanges to keep the insurance affordable.  Some people who go to the website are now being directed to apply by phone, or mail, but because the site incorporates automatic verification of personal information, that will need to be done manually by employees when people apply in other ways, this increases the cost of the program.

Though specific details on some of the issues facing the exchange have not yet been released, there are some known issues that have been discussed in the media.  One of these is the available capacity for the site.  The site was planned for a maximum of 50,000 simultaneous users.  During the first day of the exchange, the site saw up to five times that many simultaneous users.  The numbers are presented as being based off the 30,000-maximum simultaneous users to the Medicaid site, but how the actual number was determined is unknown.  An increased burden on the site due to the 36 states that decided not to create their own state-run exchange contributed to the high number of users.  It was thought that the promise of federal money to support the state-run exchanges would encourage more states to participate.

The requirements for the website have been described as “unprecedented” – not only was the website designed to handle a high number of simultaneous users, it also has to share information from multiple data sources, including the Internal Revenue Service, Social Security Administration, and Homeland Security to verify information and determine access to plans and tax credits.  Based on the number of glitches and delays seen in the first weeks of the exchange website, the testing of the launch appears to have been inadequate.  Factors that may have played a part are lack of funding due to lack of support for the Affordable Care Act by Congress, and a delay in creating the infrastructure of the system over a concern that the Act would be overruled by the Supreme Court or Congress.

Information technology experts say that lessons learned from other sites – such as state-run exchanges that have already been successfully operated, or even the Medicaid site – were not applied effectively to the exchange.  The organization tasked with oversight of the exchange – Centers for Medicare and Medicaid Services (CMS) – has little experience with managing a website of this magnitude.  It has also been suggested that the contractors hired to support the site may be less able to react because government contracting can be preferential towards older, more entrenched companies.

As more information is released, the analysis of an issue becomes more detailed and allows for more effective, deliberate solutions.  The information that is currently publicly available was used to create an initial, high level Outline and Cause Map.   (To view the Outline and Cause Map, please click “Download PDF” above. )

As an immediate, but temporary solution, an online waiting room was created in hopes that it would allow an increased number of users to be on the site at the same time.  Additionally, the ability to browse anonymously – without creating a profile – was incorporated, in hopes that this would decrease traffic to parts of the site that require personal information verification for those who are just looking at the site.

A team of experts has been tapped to fix the glitches with the site.  It’s not clear who will ultimately be responsible for the fixes, though many have recommended the creation of a new position to oversee the entire exchange.  If issues with the site continue to cause delays, the sign-up period may be extended as a back-up solution.  The administration will be watching the fixes to the site carefully and determining what more is needed.  However, they’ve got to hurry – the enrollment period ends December 15 for coverage by January 1, 2014.

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

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

New Prostate Cancer Tests Look Promising

By Kim Smiley

One in six American men will be affected by prostate cancer during their life making prostate cancer the most common non-skin cancer.  Despite the number of people impacted by this disease, screening and treating prostate cancer remains problematic and even controversial at times.

This issue can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information.  How the issue impacts the overall goals is also documented in the Outline.  In this example, there are several significant impacts that need to be considered.  The first is that it’s estimated that about 30,000 men will die from prostate cancer in the US in 2013.  The second major issue is that many men are treated unnecessarily for prostate cancer.  Unnecessary treatments are a waste of resources and the side effects cause significant suffering.  The next step of the Cause Mapping process is to build the actual Cause Map by asking “why” questions and laying out the causes visually to show the cause-and-effect relationships.  (To see a high level Cause Map for this issue, click on “Download PDF” above.)

One of the factors that leads to so many deaths from prostate cancer is that it is generally found at later stages.  Most patients have few symptoms with early stage prostate cancer and current screening methods for prostate cancer are far from perfect.  Conditions other than prostate cancer, such as enlarged prostates, can result in positives during blood tests for prostate cancer.   The positive indications of cancer then trigger needle biopsies in areas of the body no one wants biopsied.  Less than half of these follow up biopsies find cancer cells. Physical exams for prostate cancer are uncomfortable and usually only find larger cancers.  Additionally, many prostate cancers grow so slowly that they will not impact a patient’s life span and do not require treatment, but there is currently no test that can accurately determine whether a prostate cancer is dangerous.

This inability to distinguish between types of prostate cancer is what leads to so many being treated unnecessarily for prostate cancer.  Many patients opt for treatment once prostate cancer is found because they have no way of really knowing whether it’s safe to leave the cancer untreated.   But treatment is not without significant costs, both financially and in suffering.  Many of the prostate cancer treatments, such as radiation or surgery, can cause major side effects such as  incontinence or sexual dysfunction.  Most patients will willingly undergo treatment for life threatening cancers, but it’s terrible that some patients endure cancer treatments without need.

The final step in the Cause Mapping process is to find solutions.  In this example, the good news is that many researchers are working to develop better prostate cancer tests, which would rapidly lead to better patient care.   Better tests could save lives by finding prostate cancers earlier and could help reduce unnecessary treatment by identifying the more dangerous cancers.  A urine test for prostate cancer is now available that has been found to be more accurate than current screening methods.  Other research groups are working to develop other urine prostate tests with a focus on developing accurate, low cost tests that can be performed at home.  None of these tests are perfect yet, but they are a significant step in the right direction.

 

Root Cause

How Best to Prevent Patient Falls?

By ThinkReliability Staff

Though there is consensus that improvement must be made in the area of injury due to patient falls, how to reduce patient injury due to falls has raised questions about effective solutions to this problem.

According to the Agency for Healthcare Research and Quality, accidental falls contribute to patient complications in 2% of hospital stays.  Specifically in the state of Washington, where potential legislation aims to reduce the risk of patient falls, falls are found to kill or injure a few dozen patients per year.  The American Nurses Association said in a statement: “Falls are a leading driver of healthcare costs, especially for the elderly.  What’s more, Medicare and Medicaid do not reimburse hospitals for costs associated with injuries from inpatient falls, essentially increasing unreimbursed hospital healthcare costs.”  Obviously, patient falls cause an impact to both patient safety and quality of care, and may affect hospital reimbursement.

A recent fall case in Washington raised some of the concerns at the forefront of the falls prevention debate.  A patient was badly injured after he fell while being medicated with a sleeping pill (zolpidem).  A study has found that hospital patients taking zolpidem are four times more likely to fall. Some hospitals have begun phasing out zolpidem as a sleeping pill because it makes patients more likely to fall.

Most hospitals rely on a fall risk assessment for their patients to determine the level of fall prevention care required.  However, changes in patient status – such as the use of medication that increases fatigue or confusion – must cause a re-evaluation of a patient’s risk.  For hospitals that continue to offer zolpidem, its use may lead to a patient that was previously classified as a low fall risk becoming a high fall risk, leading to additional protocols or care depending on the hospital’s fall prevention plan.

Studies show that more nurses result in fewer patients falling.  Nurses in Washington have supported legislation requiring higher staffing levels.  But hospital management is concerned about the cost of this requirement, although the hospital did add 29 more nurses at the hospital where this fall occurred.   Additionally, that hospital’s Chief Nursing Officer says “What we have found is it has much less to do with staffing ratios than with having good solid reliable processes in place and following those every single time.”

Many of these processes involve bed alarms – which some studies have shown to be ineffective at preventing falls.  Additionally, as a nurse states, “You still need a person to be close enough nearby to be able to respond to the alarm.”

When looking at the causes that result in an issue impacting the organization’s goals, the analysis step may seem like the most difficult part to get through.  However, in many cases, especially where patient safety, staffing, funding and reimbursement come into play, it can be even more difficult to determine which solutions should be implemented to reduce the risk of the issue recurring, especially when studies may offer conflicting or confusing evidence about the effectiveness of various interventions.  In this case, it is particularly important that organizations determine the required reduction in risk (in this case, most hospitals are attempting to end patient injury due to falls) and the solutions (interventions) that will result in that reduction based on the needs and available resources of the organization.

Most importantly, after a specified time period, the solutions need to be evaluated for effectiveness, based on carefully determined criteria.  In this case, whatever intervention is selected to reduce injury from patient falls should be evaluated against the number of injuries due to falls at that facility.  If the risk has not been reduced as desired, additional interventions are in order.

To view the fall issue discussed here in a Cause Map, with notes about solutions under consideration for reducing fall risk, please click “Download PDF” above.  Or click here to read more.

Root Cause

Increase in Resistant Bacteria and Fungus Threatens Public Health

By ThinkReliability Staff

On September 16, 2013, the Centers for Disease Control and Prevention (CDC) issued a report “Antibiotic Resistance Threats in the United States, 2013”.  This report detailed the impacts, causes and recommended solutions related to antibiotic resistance within the US (although the concerns are similar worldwide).

The report takes the form of an incident investigation.  Specifically, the report addresses the impacts to the goals of the CDC, the cause-and-effect relationships resulting in these impacts, and what is recommended to reduce the risk of these impacts continuing. The information presented in their report can be captured in a Cause Map, or visual root cause analysis, which allows a demonstration of the interaction of the various causes presented in the report.

The report begins with the goals being impacted by the problem of antibiotic resistance.  Specifically, the CDC conservatively estimates that more than 2 million people are sickened in the US every year by antibiotic-resistant infections.  More than 23,000 are estimated to die as a result.  The risk is not just for the general public, but healthcare providers as well, who are implicated in the report as having resistant strains on their hands, which causes a health risk for them as well as patients.  The report identifies not only person-to-person spreading of infection, but also spreading from environmental causes, such as food.  The presence of these strains impacts the environmental goal as well.

The cost of these infections is staggering.  It is estimated that up to $20 billion per year is spent on direct excess healthcare costs as a result of these infections in the US alone.  The productivity cost (loss of productivity across industries due to employees being out sick) is estimated to be as high as $35 billion per year.  (While the causes discussed in the report are of concern globally, the impacts to the population are specific to the US.)

Increased illness from resistant infections results from exposure to resistant infections, decreased protection from infection, and a shortage of drugs available to treat these infections.  Exposure to antibiotic-resistant infections results from either person-to-person or environmental spread.  Spread can pass from anybody who has antibiotic resistant bacteria or fungus, but a primary source is healthcare providers, who can easily pass the infection with improper hand washing (or none at all).  Environmental causes include surfaces (again, healthcare providers are a frequent source here) but also food.  Food animals are given antibiotics to control disease, but also sometimes are given antibiotics without a diagnosis to prevent infection or promote growth.  These antibiotics kill off non-resistant bacteria but not resistant bacteria, which remains in the meat and feces.  If meat is improperly cooked, the bacteria can be passed on to humans.  But the issue is not just with improperly cooked meat.  Other foods can be contaminated with animal feces, which can also contain the resistant bacteria.

When a person is taking antibiotics, they have a decreased protection from infection.  This is because antibiotics kill all bacteria – including “good” bacteria that helps prevent infection.  While antibiotics are used to treat disease,  the CDC estimates that 50% of prescriptions are unnecessary or not optimally effective.  The use of antibiotics has been identified as the single most important factor leading to antibiotic resistance.

The increase of antibiotic-resistant bacteria (and fungi) means that more and more drugs are becoming ineffective in treating these infections, increasing the risk of death when infections occur.  Additionally, research and development into antibiotics is slowing, compounding the problem of effective drug availability.

As part of the report, the CDC provides wide-ranging recommendations to limit antibiotic-resistant infections.  The recommendations are for healthcare providers, communities and individuals.  They aim to first prevent the spread of infection by ensuring that antibiotics are prescribed and used properly, as well as by better tracking the spread of antibiotic resistant pathogens.  This includes stopping the use of antibiotics in feed animals for growth promotion.  Additionally, better cleanliness control for healthcare providers, food preparers and the general population will reduce the spread of disease.  Secondly, the CDC aims to provide better treatment for these infections by investing in research and development to provide new antibiotic treatment options.  It is also hoped that surveillance data can provide more effective diagnostic tools and use of the treatments currently available.

To view the Outline and Cause Map, please click “Download PDF” above.

Want to learn more?
Read the CDC report.
Read our previous blog on Carbapenem-Resistant Enterobacteriacae (one of the “Urgent” threats identified in the CDC report).

Root Cause

Patient Dies After Fall During Transfer

By ThinkReliability Staff

A medical center in California received a fine for an adverse event in which a patient’s fall at the facility resulted in his death.  As a part of the investigation into these types of events, a plan of action to mitigate the risk of similar events occurring in the future.  In order to best determine which events will be helpful in decreasing future risk, a full accounting of the cause-and-effect relationships that led to the incident being investigated can be helpful.  We can develop a visual map of the causes that resulted in this incident in a Cause Map, a visual form of root cause analysis which determines all relevant causes in order to offer the most possible solutions.

We begin our analysis with a summary of the “what, when and where” of the event, as well as determining which of the organization’s goals were impacted.  In this case, the patient safety goal was impacted due to the patient death.  The compliance goal is impacted because the facility was found to be noncompliant with requirements for licensure as a result of this event.  The fine from the state health department can be considered an impact to the organizational goal.  The patient services goal was impacted due to the improper transport of a patient.  Lastly, it was found that equipment was missing necessary safety features.  This can be considered an impact to the property/ equipment goal.

Once we have determined the impacts to the goals, we can begin with one impacted goal and ask “Why” questions to  determine the cause-and-effect relationship that led to the impacted goals.  In this case, we begin with the patient safety goal.  Why was the patient safety goal impacted? Because of a patient’s death.  Why did the patient die? His death was due to rib fractures and internal bleeding.  Why? Because of blunt force trauma.  Why? Because the patient fell out of a geri/bed chair (a device that can be used as a stretcher semi recliner or chair).

To ensure that the causes we include in our analysis are accurate, we include evidence wherever possible.  Evidence allows validation of the inclusion of causes on the Cause Map.  In this case, the evidence for the cause of death is provided by the autopsy report.

In addition to continuing to ask “Why” questions to add more detail to the Cause Map, we can also add additional impacted goals to the Cause Map.  For example, the patient fall out of the geri/bed chair was what caused the noncompliance with licensure that is an impact to the compliance goal.  This noncompliance caused the fine to the facility.   The patient fell out of the geri/bed chair due to inadequate transport, which impacted the patient services goal.

In some cases, more than one cause is necessary to result in the effect.  The inadequate transport was caused by the patient – who had been assessed as a high fall risk – being both left unattended and not secured in the geri/bed chair.  The patient was not secured on the geri/bed chair because it did not have straps.  It’s also possible he was not secured, and was left unattended, because the transport team, who took him to the radiology department to get an X-ray, was not aware of his high fall risk.  Although a transfer form is used to turn the care of a patient over to another team in cases such as this, there was no record on the transfer form that indicated a report being made to the transfer team that would have included information about the patient, including his fall risk.

As part of the investigation, corrective actions are required.  As is typical in these cases, many of the solutions included additional training and education to staff to reduce the risk of these events happening again.  Although usually included as part of the corrective actions for adverse events, training (or re-training) and continued education are some of the least effective solutions in terms of error recurrence.  (After all, presumably the staff had already been trained on the policies and requirements that were already in place at the time of the accident.)  More effective solutions include changes in policy that result in increased patient safety.  For example, in this case the transport policy has been updated to ensure that patients are left in locations where they can easily be monitored.  This of course will not prevent all falls, but may prevent some, and will certainly lead to staff noticing falls quickly.  Even more effective are changes in equipment to make following policies easier.  In this case, the geri/bed chair that was used for patient transport did not have a strap, even though its use was required.  It is unreasonable to expect busy staff to spend their time searching for equipment that has the proper safety equipment.  Rather, ensure that all geri/bed chairs or other transport devices have the required safety devices.  I’m sure you can imagine that it is much more likely for staff to comply with a policy requiring use of safety devices when the devices are available and by doing so, will reduce the risk of patient falls, and patient deaths.

To view the Outline, Cause Map, and recommended solutions please click “Download PDF” above.  Or click here to read the state department of health report.

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

Promising New Cancer Drugs Use the Immune System

By Kim Smiley

A promising and potentially powerful new type of cancer treatment uses the immune system to fight tumors.   The drugs are still in early testing, but reports are that they shrunk tumors significantly in 15 to 50 percent of patients.  Patients with different types of cancer have also responded, which is an encouraging sign that the new treatment may have wide spread applications.

A Cause Map, or visual root cause analysis, can help illustrate how these new drugs work and explain why researchers and the companies developing them are so excited about them.  It may seem strange to use a root cause analysis technique on something positive, but it can be just as beneficial to understand why things are going well as it is investigate when problems crop up.  If you understand why a success occurred, the information may be used to reproduce it.   Building a “success” Cause Map is the same as any other Cause Map.  You start by identifying the impacted goals and then ask “why” questions.

In this example, the safety goal was impacted because the new type of cancer treatment shows promise, and the economic goal was impacted because the stock for the companies developing the new cancer drugs rose.   The new cancer treatment being developed shows promise because patients are responding to it and it is completely different from anything being used today.  The new immunotherapy treatments use the body’s own defenses, the immune system, to fight cancer.

You may wonder why drugs are needed at all if the immune system has the ability to fight cancer.  The answer lies in a  cancer tumor’s ability to hide from the T cells, the part of the immune system that detects bacteria and other “invaders”.  Tumors produce a protein on their surface that prevents T cells from detecting them so the immune system never even knows they are there.  A very simplified explanation is that the new drugs block the protein that hides tumors and allow T cells to detect them.   Once detected, the immune system will attack the cancer.

If immunotherapy is successfully developed, it would give doctors more options in treating cancer, especially those that don’t respond to the conventional treatments.  So far the side effects have also been minimal, far less than what is generally seen with chemotherapy and radiation treatments.

Much more research is needed before this type of drug is widely available, but the findings so far are positive enough to increase stock prices and excite experts in the field.   I have my fingers crossed that the end result is everything researchers are dreaming it will be.

Root Cause

11 Patients Killed in Nursing Home Fire

by ThinkReliability Staff

A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia.  At least 11 residents died as a direct result of the fire and nearly 100 were evacuated.    A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)

The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson.   The reasons for the arson are unclear and may never be fully understood.  However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.

We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy.  We begin the analysis with the “What, When and Where” of the event, captured in a problem outline.  Additionally, we capture the impacts to an organization’s goals.   In this case, the patient safety goal was impacted due to the deaths.  There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder.  Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million.  (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.)  Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.

Capturing the  frequency of similar issues can help provide perspective on  the magnitude of nation and world-wide issues.  I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year.  There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.

Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts.  In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility.  The fire initiation, as discussed above, is believed to be due to arson.  However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.

Studies after the event showed how critical sprinklers can be to slow the spread of a fire.  On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016.  It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.

To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.

Root Cause

Health Risks to Young Athletes

By Kim Smiley

Deaths and serious injuries of young athletes make headlines every year.  So how do we ensure that participation in sports is as safe as possible?  The first step is to determine what is causing the deaths and understanding the factors involved.

The serious health risks to young athletes can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis.  A Cause Map visually lays out all the causes that contribute to an issue to show the cause-and-effect relationships to help illustrate the problem.  According to experts, some of the serious health threats to young athletes are sudden cardiac arrest, heat stroke and concussions.

The potential for concussions, especially in the more physical contact sports, has been getting a lot of attention in the media lately, but the most common cause of death of young athletes is sudden cardiac arrest.  Most cases of sudden cardiac arrest are caused by pre-existing heart conditions and the heart breaking part is that most of these are detectable and treatable.   Most of the heart conditions that cause sudden, unexpected death have few symptoms and can’t be found by a typical sports physical done in the US.  About two-thirds of the dangerous heart defects could be found by an electrocardiogram or EKG test, but these are not routinely done in the US.  The main factor preventing EKGs is the cost, which is not always covered by insurance.  Sudden cardiac arrest is also a risk that many people don’t know a lot about.

Concussions are also a risk for athletes of any age.  Concussions can have long term health consequences and occur when brain cells are damaged.  Concussions are mainly caused by impact to the head, but can also be caused by sudden jolts to the body that cause the brain to hit the inside of the skull.  Impacts during contact sports are a well-known cause of concussions, but typical sports activities like heading a soccer ball can also cause concussions.  Wearing the appropriate safety gear can help prevent concussions.  The rules of some sports also limit the more dangerous plays like helmet to helmet tackles in football.

Another significant risk to young athletes is heat stroke.  Heat stroke is usually preventable, but is still a significant risk and can cause death in extreme causes.  Heat stroke occurs when the internal temperature of the body rises above safe levels.  Young athletes are susceptible to heat stroke because many sports practice outside in hot weather. The typical modern, air conditioned life style increases the risk of heat stroke because athletes are generally less acclimated to the heat at the start of the season.  Athletes are most likely to suffer from heat stroke during the first few days of practice in hot temperatures. Gradually increasing workouts in warm temperatures to allow athletes to acclimate to the weather has been very effective at preventing heat stroke. For example, heat stroke rates dramatically decreased after the NCAA limited practice to three hours once a day for the first five days.

How quickly treatment is administered can also dramatically change the outcomes if an athlete is injured.  Quick action by trained personnel with the appropriate equipment can save lives.  According to a recent New Times Times article, only about 40 percent of high schools in the United States have a certified athletic trainer on staff and only about 70 percent have an automatic external defibrillator (AED).  AEDs are important because they can improve the chance for survival after sudden cardiac arrest by 60 percent or more.

So what is the best way to keep our young athletes safe?  This is a matter of lively debate.  Some people believe that the right answer is to require EKGs during pre-participation physicals, but the cost of performing EKGs on the 7.7 million high school athletes in the US is not trivial.  There is also the issue that EKGs, like most diagnostic tests, are not perfect and produce some false positives that would require more testing that raises costs.  Some believe the money could be better spent by hiring more trainers and buying more AEDs.  The answers aren’t simple, but the better we understand the problem the more informed the decisions will be.