By ThinkReliability Staff
Last year we wrote a blog about preventing pool injuries, specifically slipping and drowning. However, there’s a lesser known risk from a pool – getting sick from swimming. This is officially known as “recreational water illness” or RWI, and normally involves diarrhea. RWI is estimated to affect approximately 1,000 people a year (according to WebMD) and can cause death, especially in immune-compromised people.
We can perform a proactive root cause analysis to determine what causes these illnesses. Essentially, a person consumes germs by ingesting pool water that contains germs. Pool water becomes contaminated when germs enter the pool from fecal matter. (Easier said than done. Did you know that the average person is wearing 0.14 grams of fecal matter?) So please, keep fecal matter out of the pool. Take a shower before you get in and make sure your kids are using the bathroom regularly elsewhere. (Not surprisingly, kiddie pools are the ‘germiest’.)
Now, pools are treated to prevent these germs from proliferating. However, some combinations of pool chemicals and germs take much too long to work to be effective. (For example, cryptosporidium takes 7 days to be killed in chlorine.) Some pools aren’t getting enough chemicals due to inadequate maintenance. And, there’s some stuff you can put in the pool – namely urine, sunscreen, and sweat – that interacts with chlorine and reduces the effective volume in the pool. So, even though urine itself doesn’t contain germs, don’t pee in the pool. And again, take a shower.
Our solutions to RWI – take a shower, don’t perform any bodily functions in the pool, and don’t swallow the pool water. However, that works for you and your family, but what about the unwashed masses in the pool? The CDC recommends you buy your own water testing kit and test the pool water before you get in. Make sure there’s a pool treatment plan and that it’s being followed, and that all ‘accidents’ are reported immediately. (Yep, even if they’re your fault.) Then lay back, relax, and enjoy your swim.
By ThinkReliability Staff
On April 30, 2010, following a 10-day FDA inspection of a U.S. manufacturing facility, 43 name-brand over-the-counter (OTC) children’s’ liquid medications were voluntarily recalled. Although there have not yet been any reported adverse events associated with the recalled medication, the impact of the issue has been far-reaching.
There is the potential (although believed to be remote) for an impact to consumer health, which is an impact to the safety goal. Additionally, the drugs were recalled for not meeting required quality standards, which can also be considered an impact to the safety goal. The product recall, which encompassed 1,500 lots of 43 products, is an impact to both the customer service and property goal. The cost of this recall has not yet been estimated. The manufacturing facility is on hold, which is an impact to the production goal. Lastly, the time and costs associated with the investigation to determine what went wrong is an impact to the labor goal. We can record these impacts to the goals in the outline (Step 1).
Once we’ve completed the first step, we move on to the root cause analysis, or Step 2. We begin the analysis with the impacts to the goals and ask “Why” questions to complete the Cause Map. Because the FDA’s investigation report has not yet been released, the Cause Map we have so far is very basic. Essentially, the recalls occurred because unacceptable product was released to consumers. It was released because the finished product met testing requirements. However, it was unacceptable because it did not meet quality standards, because of contamination in the raw materials that were used. At this point in the map, we run into more questions. More detail can be added to this Cause Map as the analysis continues and more information is released. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.
A 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. View the investigation by clicking on “Download PDF” above.
By ThinkReliability Staff
The California Department of Public Health recently announced that a California hospital will be fined $50,000 for a situation that led to the death of a patient. On March 5, 2009, a patient died of cardiac arrest after his portable oxygen tank ran out. The patient was not breathing adequately on his own, because he had pneumonia in both lungs. A patient death is always an impact to the patient safety goals. The fine is an impact to the organization and compliance goals. Additionally, a patient’s oxygen tank running out of oxygen (regardless of whether it caused a death) is an impact to the patient services goal. These impacts to the goals give us a starting point for our investigation.
The patient death was caused by cardiac arrest, caused by insufficient oxygen. The patient had insufficient oxygen and insufficient supervision. Had the patient been properly supervised (as required), a medical staffer should have noticed the issue before it came to this point. The patient was unable to breath on his own because of the pneumonia and so was placed on oxygen. The patient was placed on portable oxygen in order to be transported to the radiology department for an ultrasound. Although there was the capability within the radiology department for the patient to be hooked up to the wall oxygen supply, there was no policy to do so, and the patient remained on the portable oxygen supply.
According to hospital procedures, when a patient is being transported, the responsibility for the safety of that patient lies with the transporter. A hospital policy allows for patients to be transported by untrained personnel in the case that a patient is stable, and this is indicated on the Transport Communication Form. This patient was transported by an untrained person; however, no Transport Communication Form was completed or signed. Whether or not the patient was considered ‘stable’ is unknown. For reasons that are unclear, the transport person left the patient in the radiology department and did not return. Eventually, the Ultrasound Technician returned the patient to his room. It was then realized that the patient was not breathing and the patient was connected to the wall supply. However, it was too late and the patient was unable to be revived. Although the Ultrasound Technician was trying to aid the patient, she did not verify that the patient was breathing, either because it was not her responsibility or she was unaware of the patient’s oxygen requirements. The transport person was both not around, and not trained for this type of work. Although the hospital policy required an RN or a Respiratory Therapist to regulate the oxygen flow rate, none were around.
Shortly after this incident, the hospital implemented new and clarified policies regarding patients on oxygen, and how they were to be transported. These solutions, along with the rest of the information from the investigation, can be seen by clicking “Download PDF” above.
Information used for this investigation was found in the report by the California Department of Public Health.