As well as medical errors and industrial accidents, the Cause Mapping method of root cause analysis can be used to research the causes and solutions to disease epidemics. Take the case of hepatitis B and C. A report recently released by the Insitute of Medicine states that the infection rates of chronic hepatitis B and C viruses (HBV and HCV) is 3-5 times that of HIV (human immunodeficiency virus). The report also outlines some of the problem associated with lowering the infection rates of hepatitis B and C.
Using the information presented in this report, it’s possible to make a Cause Map outlining the causes of hepatitis B and C infections. First we begin with the impact to the goals. First, the report estimates that there are approximately 15,000 deaths per year associated with chronic HBV and HCV. Additionally, 3-5 million people are estimated to be living with chronic HBV and HCV. These are both impacts to the patient safety goal. In many cases, these infections are not treated. This is an impact to the patient services goal.
Once we’ve defined the incident in respect to the goals, we can begin our Cause Map. We begin with an impact to the goals and ask “why” questions until all the causes are on the Cause Map. In this case, the deaths are caused by chronic HBV and HCV, which are caused when a person is infected and not treated. Infections can result from being born to an infected mother, infected blood transfusions (before blood was tested for HCV), sexual contact with an infected partner, sharing needles with an infected person, or needlesticks with an infected needle.
Most typically, people who are infected with HBV or HCV do not seek treatment because they are unaware they are infected due to the asymptomatic nature of hepatitis. Persons may not be screened even in high risk situations because either they or their healthcare providers do not realize the risk, or they do not have adequate access to healthcare.
The infection rate of HBV is decreasing thanks to a vaccine for hepatitis B. However, a vaccine is not yet available for hepatitis C. This is certainly a priority in the national fight against hepatitis infections, as well as increased education and awareness programs.
This thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. To view the one-page downloadable PDF, please click on “Download PDF” above.