By Kim Smiley
On October 30, 2012, power outages forced evacuation of a New York City hospital amidst the onslaught of Hurricane Sandy. All 217 patients in the hospital to had moved, including 20 infants staying in the neonatal intensive care unit.
This incident can be analyzed by building a Cause Map, an intuitive format for performing a root cause analysis. The first step in the process is to fill in an Outline that lays out the basic background information and also identifies the impact to the goals. In this example, the safety goal is clearly impacted because it is risky to evacuate patients during a hurricane. Although the potential for injury was very real, no one was hurt during the evacuation and the hospital staff did an amazing job of carrying patients down darkened stairwells and ensuring basic life support remained stable. The customer service goal is also worth considering since the unexpected evacuation received a large amount of negative publicity.
After the Outline is completed, the next step is to ask “why” questions to add Causes to the Cause Map. Why were patients at risk? This occurred because the hospital had to be evacuated because it lost power and the backup power generators failed. Why the generators failed hasn’t been identified yet, but there is speculation that the age of the equipment may have played a role. It’s also possible that the location of the generators might be factor since a number of hospital building were flooded by ten feet of water. Electrical service was lost because New York City was hit hard by Hurricane Sandy and saw unprecedented flooding and strong winds. This wasn’t an unexpected impact of the storm, but the hospital did not expect the generators to fail, especially so quickly. The patients were also at risk because the hospital had many patients in critical care units that required life support systems and the patients were evacuated under dangerous conditions, both inside and outside the hospital. At the time of the evacuation the hospital had lost power and patients were being carried down stairs lit by flashlights. Some patients were bought down 16 flights of stairs. The evacuation also occurred during the hurricane so the conditions during the drive to a new faculty were potentially dangerous. The evacuation occurred during the hurricane, as opposed to before the storm hit, because the hospital assured the city that it was prepared and could ride out the hurricane.
This issue is still being investigated, but once all the facts are known solutions can be developed and implemented to help ensure that patients aren’t forced to evacuate under similar adverse conditions.
Click on “Download PDF” above to see a high level Cause Map of this issue.