Tag Archives: unintended consequences

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.

Root Cause

The Willie King Case: Wrong Foot Amputated

By Kim Smiley

In one of the most notorious medical error examples in US history, the wrong foot was amputated on a patient named Willie King on February 20, 1995.  Both the hospital and surgeon involved paid hefty fines and the media had a feeding frenzy covering the dramatic and alarming mistake.

So how did a doctor remove the wrong foot?  Such a mistake seems difficult to comprehend, but was it really as mind boggling as it looks at first glance?

The bottom line is that the doctor honestly believed he was removing the correct foot when he began the surgery. The blackboard in the operating room and the operating room schedule all listed the wrong foot because the scheduler had accidentally listed the wrong foot.  After reading the incorrect paperwork, the nurse prepped the wrong foot.  When the doctor entered the operating room, the wrong foot was prepped and the most obvious documentation listed the wrong foot.  Basically, the stage was set for a medical error to occur.

The foot itself also looked the part.  The patient was suffering from complications of diabetes and both of his feet were in bad shape.  The “good” foot that was incorrectly removed looked like a candidate for amputation so there were no obvious visual clues it wasn’t the intended surgery site. Other doctors had testified in defense of the doctor saying the majority of other surgeons would have made the same mistake given the same set of circumstances.

There was some paperwork that listed the correct foot to be amputated, such as patient’s consent form and medical history.  This paperwork was available in the operating room, but no procedures in place at the time required the doctor to check these forms and these forms were far less visual than the documents where the incorrect information was listed.  Additionally, the doctor never spoke directly with the patient prior to the surgery which was another missed opportunity for the mistake to be caught.

Clearly the procedures needed to be changed to prevent future wrong site surgeries from occurring and a number of changes have been incorporated in the time since this case occurred to help reduce the risk of this type of medical error.  Surgeons in Florida are now required to take a timeout prior to beginning a surgery.  During the time out they are required to confirm that they have the right patient, right procedure and right surgical site.  This rule has been in place since 2004.

Mistakes will always happen, such as numbers being transposed or misheard words over the phone, but small mistakes need to be caught before they become big problems. Procedures like a timeout can significantly reduce the likelihood of an error going uncorrected.  In an ideal world, the simple mistake by the scheduler would have been caught long before it culminated in a surgery on the wrong body part.

A visual root cause analysis, called a Cause Map, can be built to illustrate the facts of this case.  A Cause Map intuitively lays out the cause-and-effect relationships including all the causes that contributed to an issue.  To view a Cause Map of this example, click on “Download PDF” above.

Root Cause Analysis

Safe Use of Opioids in Inpatient Hospitals

By ThinkReliability Staff

The use of opioids for pain relief in inpatient hospitals can lead to serious potential adverse effects, including respiratory depression and drug interaction.  On August 8, 2012, The Joint Commission published a Sentinel Event Alert: “Safe use of opioids in hospitals”.  The alert contains information about potential causes of the adverse effects possible with the use of opioids as well as solutions that, if implemented by healthcare facilities, can reduce the risk of patient safety impacts from the use of opioids.

We can present the information provided by The Joint Commission in a Cause Map, or visual root cause analysis.  We begin with the impacts to the goals.  In this case, we look specifically at two potential impacts to the patient safety goal – the risk of drug-drug interactions and respiratory depression involving opioids.

Drug-drug interactions can result when a patient is taking another drug that interacts with opioids. In this case, the provider prescribing the opioid is unaware of the potential interaction between the drugs prescribed or is unaware of the patient’s drug history, because a complete history is unavailable and a patient is either unable or unwilling to provide a compete list. While drug-drug interactions are possible with any level of opioid, the over-use of opioids for pain relief is a particular concern.  Opioids can be effectively used for pain relief, but over-use can occur when a high dose is needed to manage pain, either due to tolerance from chronic conditions or patient abuse, or obesity.  Studies have shown that obese patients may require more opioids for pain relief than would be suggested by their weight alone.  A patient receiving the wrong dose of opioids (besides being an issue in itself) can also contribute.  Issues have been raised regarding the difficulty in calculating doses with drugs of different potency, especially as patients move from one drug to another.  Additionally, prescribing dose based on weight alone can result in a higher or lower dose than needed as the proper dose of opioids is subject to patient weight, age, sex, and tolerance level.

Issues with prescribing the wrong dose or wrong type of medication can occur when a patient or family member is responsible for the administration.  Problems with medication administered by a provider typically occur around changes of the type or delivery method of the pain killer.  Special care should be taken to recalculate the dose  corresponding to any change in the drug dosage, type or delivery method.  Similar-looking bottles and similar-sounding names are always a potential pitfall in proper drug administration and special care should always be taken in these cases.

Opioids reduce respiratory rate, which can result in respiratory depression.  Respiratory depression can be impacted by other factors, such as a patient who is sleeping (most respiratory depression occurs during typical sleeping hours), or who is already pre-disposed to respiratory depression.  This most commonly occurs with post-surgical patients (who may have residual anesthesia), old or young patients (who may be affected more greatly by the respiratory effects), patients who have abnormal respiratory control due to obstructive sleep apnea or morbid obesity, patients with supplemental oxygen and patients who have a self-administered drug delivery system, such as a fentanyl patch.  Special care and monitoring should be taken with patients who have a higher risk level for respiratory depression.

However, monitoring for respiratory depression is difficult.  Visually assessing respiratory depression (especially while a patient is sleeping or on supplemental oxygen) is extremely difficult.  Using pulse oximetry can result in misleading values (including normal values while a patient is suffering from respiratory depression) and high false alarms.  Because respiratory depression occurs gradually, intermittent monitoring may not be sufficient to pick up on a patient’s decline.

There is no one-size-fits-all solution for reducing respiratory depression.  Rather, an individualized plan based on patient pain requirements and risk factors is shown to be the recommended way to reduce the risk of respiratory depression and ensure proper pain control for patients.

To view the Cause Map and recommended solutions, please click “Download PDF” above.  Or learn more from The Joint Commission Sentinel Event Alert.

Root Cause Analysis

Consumption of Small Cigars Increases

By Kim Smiley

A study by the CDC has found a decrease in cigarette smoking, but a corresponding increase in the use of other tobacco products.  Cigarette smoking declined 33% between 2000 and 2011 which would be cause for celebration except for the fact that use of other kinds of tobacco grew by 123%.  This seems to be an example of unintended consequences where the attempt to control one problem changed behavior in an unexpected way.

A Cause Map, or visual root cause analysis, can be used to help explain this situation.  Building a Cause Map can illuminate the cause-and-effect relationships between the different factors that contributed to an incident.  To begin a Cause Map, the impacts to organizational goals are determined and then “why” questions are asked to add Causes.  In this example, we’ll focus on the increase in the use of small cigars since they are the tobacco alternative most similar to cigarettes.  We’ll also focus on the Safety Goal since public health is affected by the increasing use of small cigars, although there are certainly other issues such as missed tax revenue worth considering in a more detailed Cause map.

Why is the risk to public health increasing?  This occurs because more people are using small cigars and they have similar health risks to cigarettes because they contain the same toxic chemicals.  Why are more people using small cigars?  Small cigars smoke similarly to cigarettes, are far cheaper than cigarettes and can taste better.

Small cigars are slightly larger than cigarettes, but are similar enough in size to provide a similar smoking experience.  They are far less expensive than cigarettes because they are in a different tax category because of their slightly larger size and the fact that not all tobacco products are equally taxed.  The price difference is significant; small cigars may cost as little as $1.40 a pack while cigarettes sell for $4 or $5 a pack since they are highly taxed to discourage smoking.

Cigars can also taste better because manufacturers are allowed to add flavorings such as grape and chocolate to small cigars, but they are not allowed to add them to cigarettes.  The Food and Drug Administration has regulations that bar adding flavoring to tobacco, but these do not apply to cigars and pipe tobacco.

From 2010 to 2011, the overall use of smoked-tobacco decreased by less than 1%.
It appears that attempts to discourage smoking cigarettes with high taxes just pushed some people into buying cheaper alternatives.  One potential solution to this issue would be to equalize the taxes and regulations on all types of tobacco.

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

Root Cause

Can Safety be Taken Too Far?

By Kim Smiley

Sometimes, what seems like a very simple, easy solution turns out to be much more complicated.  Unless a system is very well understood, implementing a solution can have unintended consequences.  Take for example, the changes made to playgrounds over the past couple of decades.  There was concern that children were being injured while playing, especially from falls from high playground equipment.  Removing any playground equipment that was deemed dangerous seemed like an obvious solution to this problem.

Gone are the metal merry-go-rounds and the ten feet tall monkey bars that many of us remember from our youth.  Modern playgrounds are populated by lower, enclosed platforms and soft ground coverings to prevent injuries and protect against lawsuits.

But are modern playgrounds better? According to a recent New York Times article , the answer isn’t the slam dunk you might expect.  There is mixed evidence about whether modern playgrounds actually reduce the number of injuries because children tend to take more risks on “safer” playgrounds.  There is also evidence that the value of playgrounds in childhood development might have been diminished by the increased focus on safety.

A recent paper by Norwegian scientists discusses the value of allowing children to face fears through “risky” play.  The concern is that children are developing more anxieties because they are losing the opportunity to face their fears by tackling challenging playground equipment. Part of the problem is also that safer playgrounds tend to be more boring which discourages children from playing at all.

There are a number of researchers asking whether the potential negative emotional impact of safer playgrounds outweigh the risk from physical injuries associated with taller, riskier playground equipment.  This is a hard question to answer because while it’s relatively easy to measure the number of bones broken on playgrounds, it’s very difficult to measure the intangible benefits of challenging playgrounds.

So can playgrounds be too safe?  It’s not clear that we have a definitive answer to that question, but what is clear is that the problem of playground safety is more complicated than originally assumed.  A Cause Map, a visual root cause analysis, can be built in cases like this to help clarify all known information.  Cause Maps are a very versatile format.  They can be created to incorporated any level of detail needed and can be added to as more information becomes available or as unexpected complications pop up.  To view a high level Cause Map of this problem, please click on “Download PDF” above.