On June 24, 2010, a patient at a Maryland Hospital was physically assaulted by security guards after trying to leave the hospital. A patient who is injured or killed due to physical assault is one of the ‘Never events’, i.e. medical events/errors that should never happen.
We will look at the causes of this event in a Cause Map, or visual root cause analysis. The information used to put together this analysis is from the legal filing.
On June 23, 2010, a man (who we’ll call “the patient”) was in a serious car accident and was airlifted to a Maryland Hospital. He woke up the next day, after receiving treatment for blunt torso trauma and chest pain and asked for something to eat. After some confusion, the patient realized that his identification bracelet was not his – it identified a female patient 13 years his junior. At this point, he decided to leave the hospital and was stopped with a verbal and physical exchange with several security guards. He eventually was able to leave successfully, and was treated at a second hospital for broken ribs, a sprained shoulder, a ruptured spleen, and a concussion.
As mentioned before, physical abuse of a patient is a “Never event”, and is an impact to the compliance goal. More importantly, there was injury to the patient, resulting in an impact to the safety goal. Because the patient was wrongly identified as needing surgery to remove a cancerous mass, there was the potential for the patient receiving unnecessary surgery, also an impact to the safety goal. The patient has taken legal action against the employees involved (Employee Impact goal) and has filed a lawsuit against the hospital for more than $12 million (an impact to the organizational goal). The misidentification of the patient can be considered an impact to the patient services goal.
We begin our Cause Map with these impacted goals. The patient was beaten because employees were trying to restrain the patient to keep him from leaving, and restrained him in an inappropriate manner. The employees were trying to get the patient to stay because they believed he needed surgery because he was misidentified. At this point, the hospital involved should be asking “Where did our identification procedure go wrong?” The next step in the investigation should be to look at the identification procedure to determine specifically which steps allowed the misidentification to happen. Only once this is determined can appropriate corrective actions be taken to prevent future misidentifications.
Another area that requires more analysis is the patient restraint procedure. The security guards in this instance were attempting to restrain the patient to prevent him from leaving. However, they did this in an inappropriate manner. The question is, why? Were the guards not following the existing restraint procedure? If not, why not? Or, is there no procedure for restraint? Were the restraint expectations not clearly provided to the guards? Again, until the specific breakdowns leading to this incident are uncovered, corrective actions will be generic and may not be effective. To view a one-page PDF showing the investigation at this point, click on “Download PDF” above.