All posts by Angela Griffith

I lead comprehensive investigations by collecting and organizing all related information into a coherent record of the issue. Let me solve a problem for you!

Which ankle needs surgery? Neither? Oops . . . (Wrong Procedure)

By ThinkReliability Staff

A patient receiving the wrong procedure is a very serious event. It has been named a “never event” by The Joint Commission. For organizations that are trying to prevent these kinds of serious events from happening, there is value in looking at near misses, such as the case we’ll examine here in a root cause analysis. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

In our case, a patient was prepped for a surgery he didn’t need, even receiving spinal anesthesia. He was prepped for a procedure based on the advice of an orthopedist, who believed the patient to have an ankle trimalleolar fracture, which he did not.

Why did the orthopedist believe the patient to have a fracture? The radiologist who had reviewed the patient’s radiographs diagnosed the fracture. The orthopedist did not review the radiographs. The orthopedist did examine the patient’s ankle, but gained no new insight into the diagnosis. Additionally, the family/patient did not mention the previous diagnosis, possibly because they weren’t told of it, or didn’t understand it..

The radiologist diagnosed the fracture because there was a fracture shown on the radiographs, which were labeled with the patient’s name. However, it was later determined that the radiographs were actually of a previous imaging client. The radiographs were taken because the patient’s previous radiographs did not arrive in time.

Given no more information about this case, our analysis stops here. However, the next step for the medical facility involved would be to examine the radiography procedures to ensure that mislabeling incidents do not occur. Other causes listed in the map can also be examined, to determine where other improvements can be made.

Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals..

Patient Killed By Operating Room Fire

By ThinkReliability Staff

In a previous blog, we looked at possible causes of patient burns, including operating room fires.  Sadly, on September 8th, a patient passed away, six days after being burned during surgery.  (See the news article.)  Due to patient safety laws and ongoing investigations, there is no information suggesting what could have been the causes of the fire.  However, as with any fire, an operating room flash fire, like the one suspected in this case, requires 3 things:

1)  a heat source – typically in the operating room the heat source is provided by electrical surgical equipment.

2) oxygen – patients under anesthesia may be receiving 100% oxygen, providing an extremely oxygen-rich environment for fires.

3) fuel – the disposable synthetic fabrics primarily used now are more flammable than cloth drapes.

Since all three of these causes are required for a fire, removing any one of the causes will prevent a fire.  However, in an operating room environment it’s not practical to remove any one of these causes, so instead we can work on reducing the risk by mitigating the effect of each of these causes.  To reduce the risk from the heat source, surgeons are warned to leave electrical tools in standby mode, or turned off, whenever they are not in use.  To reduce the concentration of oxygen in the air, anesthetists may be asked to provide only as much oxygen as needed for the patient, and avoid creating places that oxygen may concentrate, such as under the drapes.  More flame-resistant material is being considered for use in some operating rooms.  Additionally, more and more operating room teams are providing training in preventing and extinguishing surgical fires, because although only an extremely small percentage of surgeries result in fire, the results can be catastrophic.

Sorry alone doesn’t work unless we learn from our mistakes.

By ThinkReliability Staff

The title is a quote from Timothy McDonald, a pediatric anesthesiologist and the chief safety officer of the University of Illinois Medical Center, discussing medical errors, which are now estimated to kill as many as 98,000 Americans a year.

“We have to also make promises that this won’t happen again and get patients and families engaged in the effort to improve our performance.”

The University of Illinois Medical Center, along with other medical facilities, has made great efforts to communicated with grieving family members after medical mistakes, and getting those family members involved with helping prevent future mistakes.

One of the changes implemented requires an x-ray of patients at risk for foreign objects retained after surgery. So far, the x-rays have found 8 foreign objects found left in patients , despite a manual count that claimed all the sponges were accounted for.

Some experts worry that the “increased candor” with families may increase the number of lawsuits. Dr. McDonald says that, though the number of procedures at the University of Illinois Medical Center have increased 23% since the program was implemented, the number of lawsuits has decreased 40%.

To many family members of victims of medical errors, it’s not about the money; it’s about making sure nobody else will suffer from the same mistake. Allowing these family members (or the victims themselves) to help improve the processes that led to the errors may ease their concerns. (View the news article in the Wall Street Journal.)

Emergency Generators: A Loss of Power Doesn’t Mean a Loss of Life

By ThinkReliability Staff

If you are working at a healthcare facility, you most likely have an emergency generator. However, that emergency generator probably powers only certain critical sections of the facility, and it probably doesn’t include the administration part of the building. Why is that so?

We can look at impacts to the goals to determine why a solution that’s successfully implemented to solve a problem at one location or organization may not be the right solution for another organization. In a hospital, a loss of power could impact the goals pretty severely – the risk of death to the patients impacts the safety goal, the loss of life-saving equipment impacts the customer service goal. Additionally, the production goal may be impacted because the facility is unable to enter new patients. Last but not least, an additional cost (impact to the materials/labor goal) may be incurred transferring patients to a new facility. Obviously the risk of death means a HUGE impact to the organization’s goals, demanding comprehensive reliability solutions.

Compare this to an office building, such as where our administrative offices would be. If a loss of power occurred, the goals would be impacted – employees could get injured leaving the building if the lights went out. This is an impact to the safety goal. We may lose our business function during the outage, which would be an impact to the customer service and production goals. Additionally, we may have to pay our employees for a non-work day. The goals are impacted, but the severity of the impacts pales compared to the impacts of a hospital or medical facility losing power.

If we create a Cause Map based on these impacts to the goals, it shows that all the impacts to the goals tie back to a loss of electrical power, caused by both a power outage AND a lack of back-up electricity source. (The Outline and Cause Map are shown on the downloadable PDF.)

When determining solutions, there are a few that come to mind, including transferring patients to another healthcare facility (which becomes an impact to the goals) and installing battery backups in equipment. However, because of the severe impacts to the goals, a hospital will likely decide that the whole problem can be solved by installing an emergency generator. Problem solved; we have been able to find the best solution.

The administrative offices may feel differently. The cost of installing an emergency generator is large, and if we compare that cost to the costs that would be incurred due to a loss of power without backup, it’s probably not worth it. Instead, the office building may implement solutions further to the left on the Cause Map, such as installing emergency lighting, or using battery backups, that would mitigate (but not prevent) the impacts to the goals. So, just because a solution was the “right” solution in one case, it may not be in every case.

View the Outlines and Cause Maps for both the hospital and office building by clicking “Download PDF” above.

View the Joint Commission’s article on Power System Failures.

We Regret to Inform You We’ve Removed the Wrong Leg . . .

By ThinkReliability Staff

Performing surgery on the wrong body part or wrong-site surgery is a “never event” as defined by the National Qualify Forum (NQF), and can have serious health consequences for a patient.

We can use a Cause Map to determine some ways to prevent wrong-site surgery. Some of the common errors leading to wrong site surgeries are presented in the Cause Map found on the downloadable PDF. They include: time pressure, lack of paperwork, misreading radiography, not marking or incorrectly marking the surgical site, and marking the wrong site.

Once the root cause analysis is complete, solutions are brainstormed and placed with the cause they control. In this example, we use the solutions to create a basic Process Map for the surgical preparation procedure to prevent wrong site surgeries. The solutions are numbered based on the order they appear on the Process Map. It’s clear that consistent adherence to this Process Map would result in fewer wrong-site surgeries.

Click on “Download PDF” above to download a PDF showing the Cause Map and Process Map.

Go to Root Cause Analysis Healthcare Home Page

UTIs: Painful for the Patient AND the Hospital, too!

By ThinkReliability Staff

According to Medicare data, there were 12,185 cases of Catheter-Associated Urinary Tract Infections (UTIs) in the year 2007, which resulted in an average $44,043 hospital stay. These cases represent more than $500 million in this preventable, hospital-acquired condition. As a result, Medicare and Medicaid will no longer cover costs associated with UTIs if they were not present at admission to a medical facility.

In order to work at preventing these conditions, first we must examine how they occur. We’ll do this by looking at Catheter-Associated Urinary Tract Infections in a visual root cause analysis (or Cause Map).

A UTI is an impact to our patient safety goal. A UTI is caused by pathogens accessing the urinary tract and not being removed. We will look at each of these causes in more detail. Pathogens access the urinary tract when a urinary catheter is inserted. The catheter may be used for obtaining urine, because a patient is incontinent, or to permit urinary drainage.

In order for pathogens to access the urinary tract on a catheter, there must be pathogens on or in the catheter. These can be pathogens already in the body, contamination from the drainage system, or pathogens transferred on the hands of medical personnel, or by a non-sterile insertion.

The pathogens are not removed from the body either because of an insufficient immune response caused by damage to the urinary tract by improper insertion or improper securing of the catheter. Or, the pathogens are not excreted due to an obstructed urinary flow.

Once we have determined the basic causes of a UTI from our simple root cause analysis, we can consider solutions associated with the causes. For example, if a cause is “Pathogens on hands of medical personnel”, a solution may be to require “Handwashing before and after manipulation of catheter site or apparatus.”

Click on “Download PDF” below to see the Cause Map and possible solutions. If facilities began implementing some or all of these solutions, the incidence of Catheter-Associated UTIs would decrease, and patient health and satisfaction would increase.

Implement Solutions Within Your Sphere of Influence

By ThinkReliability Staff

The Houston Chronicle reports disturbing news on the state of healthcare safety and reform.    They reported that:

“Experts estimate that a staggering 98,000 people die from preventable medical errors each year”

“A federal Centers for Disease Control and Prevention study concluded that 99,000 patients a year succumb to hospital-acquired infections. Almost all of those deaths, experts say, also are preventable.”

Not only do almost 200,000 people a year die from preventable errors or infections acquired in hospitals, but, according to expert federal analysts, the rate of these deaths may actually be increasing.  Part of the problem is that the recommendations provided by experts, federal and private studies and various other resources are not being implemented quickly – or at all.

Some people think that the root cause analysis investigation process ends when solutions are recommended.  In fact, the hardest part may be just beginning.  There’s a reason we refer to solutions as “action items” – they require action.  They also require follow-up.

Proper follow-up will determine if solutions are being effectively implemented, i.e. the problem is being solved.  In this case, that would be the number of medical errors are decreasing.  Since that’s not happening, the next step is to determine why the action items were ineffective.  Right now, the recommended action items aren’t effective because they aren’t being implemented.

An organization can only effectively implement solutions that are within its sphere of influence.  Medicare, for example, is attempting to influence medical errors by using its most effective weapon – its pocketbook.  Medicare is no longer reimbursing for certain medical errors, and hopes to add to the list.  As many private insurers follow suit, more healthcare facilities will find it necessary to change the way they do business . . . and then hopefully the medical error rate will begin to decrease.

Learn more about finding solutions.

Fighting Back Against Drug-Resistant Malaria

By ThinkReliability Staff

A study published in the New England Journal of Medicine shows that malaria is becoming resistant to the most effective anti-malarial drugs currently available, known as artemisinin-based combination therapy. This therapy involves two drugs – artemisinin, which acts and leaves the body quickly for a “shock” to the parasites that cause malaria, and mefloquine, or another related drug, which stays in the body longer and cleans up the rest.

Since there are currently no equally effective replacement drugs or a vaccine for malaria, an increase in the drug-resistance of malaria may increase the number of deaths from malaria. In 2006, malaria was responsible for nearly 1 million deaths, according to the World Health Organization (WHO).

A Cause Map built using a root cause analysis template can visually explain the causes leading to drug-resistant malaria in a simple, intuitive format that fits on one page. (To view the Cause Map, click on “Download PDF” above.)

A risk in the increase in deaths from malaria is caused by people being infected by malaria, and ineffective malaria treatment. Nearly 250 million people a year are infected with malaria, due to exposure to mosquitoes in an endemic area, no vaccine and no preventive drugs (which are expensive and can have side effects with long-term use). Ineffective malaria treatment can be due to counterfeit drugs, which are estimated by WHO to comprise up to 40% of the drug supply. Counterfeit drug distribution is increasing due to a lack of security of the drug supply.

Additionally, the increase in drug-resistant malaria means that existing treatments are less effective. (Counterfeit medicines are a double whammy in that they also contribute to drug resistance.) Drug resistance generally occurs when an infected person takes a not-quite-whole course of treatment. The treatment kills off most of the bugs, leaving only those strong enough to resist. When these “super” bugs then reproduce, the resulting generations are more likely to be drug resistant. (This is what’s been happening in the U.S. with some antibiotics.)

The most effective (and WHO recommended) course for malaria is the combination therapy discussed above. Unfortunately, the mefloquine class of drugs have severe adverse side effects, including nausea, vomiting, and nightmares. When the two medications are given separately, some people chose not to take all (or any) of the mefloquine to avoid these side effects. A possible solution is to only offer the two together, in a combination pill.

The WHO and other organizations continue to work on this problem. An experiment in Europe recently used weakened mosquitoes as “flying vaccines” for malaria, with some success. Until then, the use inexpensive preventive measures such as mosquito nets and indoor spraying continues to increase.

To learn more about diseases carried by mosquitoes, see our yellow fever blog posting.

Addressing Systemic Failure at the Nation’s Hospitals

By ThinkReliability Staff

A Medicare analysis (see the news report) has shown that a small (but significant) group of hospitals have much higher than average death rates from pneumonia, heart failure, and heart attacks.  Additionally, the study found that one in four heart failure patients (and a similar but smaller percentage of pneumonia and heart attack patients) have to return to the hospital within 30 days.

Hospitals are in the business of solving problems.  So, what do the results of this study tell us about problem-solving?  Statistics like this point to a systemic failure.  Systemic failure indicates an inability of the system (in this case, hospitals) to achieve their goals (improving patient health).  Although statistics can help determine if there is a problem, statistics themselves do nothing to solve the problem.

A root cause analysis investigation can be a useful tool to determine the causes of systemic failure.  The investigation can be performed by anyone with the authority to effect change – for example, Medicare itself could perform the analysis, with results and associated suggestions for improvements being provided to its associated hospitals.  Or, an individual hospital can perform an investigation itself, using its own data and experience.

This seems like a monumental task – just considering one in four heart failure patients results in a staggering number for any hospital.  However, an investigation of systemic failure does not require an analysis of each individual case.  Instead, begin with one specific case.  Dig up all the information on one patient who returned to the hospital after treatment, and perform a comprehensive root cause analysis investigation on that case.  Because this specific case is part of a systemic issue, properly implemented action items (solutions) will improve the care at the hospital as a whole, thus reducing the number of cases that make up the systemic issue.

Once this has happened, the job isn’t done.  After solutions are implemented, their effectiveness must be verified.  For large systemic issues, implementing action items from one investigation may not be sufficient to “solve” the problem (allow the hospital to achieve its patient health goals).  If this is the case, other specific incidents can go through the same root cause analysis investigation process, one at a time, until the implemented solutions allow the hospital(s) to operate in a satisfactory manner.