A series of errors resulted of the death of a young mother in Romford of the United Kingdom on November 11, 2011. Details of the patient’s condition and care provided by a local hospital during a bout of appendicitis were recently released. We can look at the causes that led to her death – and the death of her unborn baby – in a Cause Map, or visual root cause analysis.
With a complex issue taking place over several days like this one, it can be helpful to develop a timeline to aid in understanding. In October, 2011, the 5-months pregnant patient entered the hospital and was diagnosed with appendicitis. Surgery to remove her appendix occurred on October 23rd. On the 29th, the patient was discharged from the hospital. The pathology results became available on October 31st. These tests indicated that it was not the appendix that had been removed, but an ovary. However, the results were not read by any hospital staff at this time.
The patient returned to the hospital on November 7, still in pain. On the 9th, she suffered a miscarriage, at which point the pathology tests were read. The patient underwent surgery to remove septic fluid from the diseased appendix, which had not been removed. Two days later, on the 11th, the patient underwent a second surgery to remove her appendix, and died during the operation.
Before beginning an analysis it’s important to determine which organizational goals were impacted as a result of any issue being analyzed. In this case, the patient death and miscarriage are both impacts to the patient safety goal. (Both the mom and baby can be considered patients.) As a result of the issues related to the patient’s death, eight hospital staff are being investigated, an impact on the hospital’s employees. The death of a patient related to the wrong procedure being performed – in this case, the wrong organ was removed during her appendectomy – is a “Never event”, which is an impact to the compliance goal. The Hospital Trust has accepted liability for her death, an impact to the organization. The wrong organ being removed is an impact to the patient services goal. Additional required surgeries are an impact to the labor goal.
To perform our root cause analysis, we begin with an impacted goal and ask “Why” questions. In this case, the patient death was due to multiple organ failure. The multiple organ failure occurred because the patient had sepsis, and the sepsis was not immediately recognized. (Although it appears that nothing was done to deal with sepsis until two days after the patient returned to the hospital, details on what was done have not been released.) The sepsis resulted from the patient having appendicitis, and the appendix not being removed for 19 days. Why was the appendix not removed for 19 days? Instead of removing the appendix during surgery, the patient’s ovary was removed. The results of the pathology report (which would have identified that the organ sent was not an appendix) was not read when available. It is also not clear what the process was for reading these reports at the hospital, and how that process is being fixed. It is known that the pathologist did not do any special reporting of the adverse results.
Now we get to the question, why was the wrong organ removed in the first place? The surgeons were attempting to remove the appendix, which was inflamed as the patient was suffering from appendicitis. Because they were performing open surgery, rather than laparoscopic, and the uterus was in the way of the appendix (due to the pregnancy), the surgery was being performed by feel, rather than sight. (As you can imagine, this makes the surgery more difficult.) During the surgery by feel, the ovary was mistaken for the appendix. The ovary was possibly inflamed, due to the pregnancy, but another important issue is that the surgery was performed with overall inadequate expertise – specifically by trainees with no senior medical staff present. (Senior medical staff were not required to be present, but due to the admitted difficulty of this type of surgery, that may have been a good move.)
As with many medical mishaps, any number of staff members could have improved the patient’s outcome. Specifically, though the pathologist was only tangentially involved in the patient’s case, had she or he called the patient’s team immediately upon noticing that what was labeled an appendix was actually an ovary, the patient’s (and baby’s) life would likely have been saved. Patient safety depends on everyone.
To view the Outline and Cause Map, please click “Download PDF” above.