A patient with schizophrenia and dementia was discharged from a New York City emergency room alone and without effective treatment. Less than two hours after her discharge, she was taken via ambulance to another hospital, which performed emergency surgery on a perforation in the digestive tract. However, because of various communication issues, the family was not notified of her whereabouts until three days later.
Multiple factors were involved in this issue. To provide some clarity about what happened, and where the investigation should go next, we can put the information that is known into a Cause Map, or visual root cause analysis. The Cause Map can be expanded as more information is known.
The first step of any problem investigation is to determine what problem needs to be solved. Rather than attempting to define a complex issue as just one “problem”, the problem is defined as the impact to an organization’s goals. In this case, patient safety was impacted due to the risk of injury to the patient. The regulatory goal is impacted due to the risk of a lawsuit or other regulatory action. Patient services were impacted because of the improper discharge. Additionally, the labor/ time goal is impacted because of an investigation, which the “first” hospital (or regulatory agency) should be performing, although the hospital has not released any information, citing privacy concerns.
The second step of a problem investigation is the analysis. We begin the analysis with one of the impacted goals. To develop the cause-and-effect relationships that make up the Cause Map, we ask “why” questions. In this case, the patient safety goal was impacted because of the risk to the patient. The risk was caused by being discharged alone, and also by being discharged without proper treatment. Because both of these causes resulted in the impact, they are joined with an “AND”. The patient was discharged improperly based on a decision to discharge the patient. Because the first hospital has not released any more details, we have to end that line of questioning with a “?”. However, once the causes related to the patient being improperly discharged are determined, solutions that will improve the discharge process to reduce the risk of other patients being improperly discharged can be brainstormed and implemented.
To ensure the analysis is complete, the other impacted goals must also be addressed. In this case, the labor/ time goal is impacted by the investigation. The investigation results from the patient being discharged improperly (also an impact to the patient services goal) and the hospital’s delay in notifying the family of the patient’s whereabouts. The second hospital did not have the family’s contact information because it was unable to receive it from the first hospital. This is another area that will need to be investigated further. Although the second hospital treated the patient after deeming it was an emergency, the second hospital had no way of contacting the patient’s family. This is particularly important in this case as the patient’s son was designated to make medical decisions for her. Additionally, even though the second hospital notified the first hospital it was treating the patient on the day the patient went “missing”, the first hospital, despite frequent contact with the patient’s family, did not pass that information along until three days later. The communication breakdowns at the first hospital must be addressed.
The third step of a problem investigation is to determine solutions to reduce the risk of similar issues recurring. In this case, more detail is needed about the discharge and communication processes. The solutions will ideally improve those processes to ensure that discharges and communication about patients are made following proper protocol.
To view the initial problem investigation, or Cause Map, click on “Download PDF” above. Click here to see our previous blog about intentional improper patient discharge, or “patient dumping”.