On December 31, 2010, a patient entered St. James’s Hospital in Leeds for a urinary tract infection. Unfortunately for the patient, the hospital was experiencing nursing shortages due to the holiday and the patient died 3 days later. The death of the patient is an impact to the patient safety goal. We can look at this incident in more detail, based on the information available, in a root cause analysis presented in a visual Cause Map format.
Besides the impact to the patient safety goal, there was an employee impact due to the staffing shortage. The patient’s son noted mistakes in the patient notes and charts (an impact to the compliance goal) and received a settlement from the National Health Service (NHS). Last but certainly not least, the patient services goal was impacted due to the delay in appropriate treatment that the patient experienced.
To add more detail to the Cause Map, we can ask “why” questions. The patient’s death was due to the combination of a urinary tract infection and the delay in appropriate treatment. The urinary tract infection was caused by a catheter in place as the patient was bed-bound due to a previous stroke. The delay in treatment was two-fold: first, the patient was not given another dose of antibiotics for 24 hours after the initial dose administered in the emergency room. Second, the medication that was eventually given was not effective as the infection was resistant to that particular antibiotic. The junior doctor who prescribed the medication failed to notice the antibiotic resistance and there was no over check of the prescription, likely due to the staffing shortage.
The patient was not monitored for 15 hours during the first 24 hours she was in the hospital. Neither the nurses (again, likely due to the shortage) nor the consultant who performed morning rounds monitored her during this time. This likely also led to mistakes in the patient’s notes and chart (which her son says number 140) and contributed to the patient’s death. The NHS and hospital involved have developed an action plan to ensure that lessons are learned from this incident.
To view the Outline and Cause Map, please click “Download PDF” above.