Tag Archives: discharge

Root Cause Analysis

Deadly medication error illustrates danger of discharge period

By ThinkReliability Staff

Medical errors can happen anywhere and at any time. However, these errors may be most likely to occur at transitions, especially the transition from the hospital to home when follow-up care is still required. Says Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine, “Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs. The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

The case of a woman’s death from medication errors during that transition period illustrates multiple errors that can occur during this period. We will capture the known details of this issue in a Cause Map, or root cause analysis. The first step in the Cause Mapping process is to capture the what, when, where and impacted goals in a Problem Outline. In this case, the patient passed away October 30, 2013, after discharge from a regional medical center in Missouri, where the patient was treated for congestive heart failure. Organizational goals that were impacted by the patient death (an impact to the patient safety goal), settlements with both the hospital and pharmacy (impacts to both organization’s legal/ financial goals), and the patient being administered a high dose of the wrong medication (an impact to the patient safety goal).

These impacts to the goals become “effects” of cause-and-effect relationships. The Cause Map contains all the cause-and-effect relationships that led to these impacted goals. Causes included in the map are verified with evidence, which can be provided by a variety of sources. Causes can be determined by asking “Why” questions, but more than one cause may be required to produce an effect. In this case, all necessary causes are included and joined with an “AND”.

The patient safety goal was impacted because of a patient’s death due to multiple organ failure when her bone marrow became unable to create blood cells as a result of an overdose of methotrexate. Methotrexate can damage blood cell counts and is primarily used to treat cancer and severe arthritis. The patient was administered a high dose (for methotrexate) of a drug that was not prescribed for her. When the patient left the hospital, the hospital phoned an order for a daily dose of the diuretic metolazone. However, according to court evidence, the order was written down by a pharmacy technician as a daily dose of methotrexate.

Because of the side effects of methotrexate, it is included in a list of eight “high-alert” medications that warrant special safeguards to prevent incorrect dispensing. The typical dose of methotrexate is much lower, usually only once or twice a week. Despite this, the pharmacist missed the error. In a testimony, he was unable to identify a specific reason for this oversight. The pharmacy manager said “there was a breakdown in the system.”

There were more opportunities for this error to be caught before this drug was dispensed to the patient. The patient herself could have noticed the incorrect medication based on the name or information on the enclosed information sheet. However, the patient likely did not fully understand the discharge instructions. Federal data shows that less than half of patients say they’re confident they understand discharge instructions. This patient was also receiving home health care, but neither of the two nurses that saw the patient identified the medication mix-up. Even though a primary purpose of home health care is to develop and follow-up on patient care, a 2013 government report found that more than a third of facilities did not do this properly. Medicare requires that home health agencies verify patient’s medications and check for possible interaction, but inspectors found that nearly a quarter of home health agencies inadequately reviewed or tracked medications for new patients. One of the challenges is that the typical providers of post-discharge patient care (nursing homes, rehabilitation facilities and home health care providers) did not receive any of the funding provided by Congress to upgrade to electronic medical records.

Several systemic issues were identified in this case and actions meant to improve these issues are still ongoing. One reason for increased use of electronic medical records is to avoid delivering prescriptions over the phone, which can result in transcription errors. Ensuring patients better understand their discharge instructions is another goal that could improve patient safety. Lastly, improvements to home health care agencies to ensure their required tasks are being completed effectively is clearly needed, but it has been difficult to determine the most effective way to do this.

To view the Cause Map of this incident, click on “Download PDF” above. Or, click here to read more.

Root Cause Analysis

Study finds many patients don’t understand their discharge instructions

By Kim Smiley 

Keeping patients as comfortable and safe as possible following hospitalization is difficult if they aren’t receiving appropriate follow-up care after returning home.  But a recent study “Readability of discharge summaries: with what level of information are we dismissing our patients?” found that many patients struggle to understand their follow-up care instructions after leaving the hospital.  

Generally, follow-up care instructions are verbally explained to patients prior to discharge, but many find it difficult to remember all the necessary information once they return home.  The stress of the hospitalization, memory-clouding medication, injuries that may affect memory and the sheer number of instructions can make remembering the details of verbal follow-up care instructions difficult. 

In order to help patients understand and remember their recommended discharge instructions, written instructions are provided at the time of discharge.  However, the study found that many patients cannot understand their written follow-up care instructions.  The study determined that a significant percentage of patients are either functionally illiterate or marginally literate and lack the reading skills necessary to understand their written instructions.  One assessment found that follow-up care instructions were written at about a 10th grade level and another assessment determined that the instructions should be understood by 13 to 15-year-old students.  

One of the causes that contributes to this problem is that discharge instructions are written with two audiences in mind – the patient and their family as well as their doctor.  Many patients need simple, clear instructions, but other doctors understand medical jargon and more complicated care instructions.  

It is important to note that the study did have several limitations.  Researchers did not give patients reading tests and instead relied on the highest level of education attained to estimate literacy skills.  Non-English speakers were excluded.  Even with this limitation, the study provided information that should help medical professionals provide clear guidance on follow-up care recommendations. 

The obvious solution is to work towards writing care instructions that are as simple and clear to understand as possible. In order to help patients clearly understand their follow-up care instructions, the American Medical Association already recommends that health information be written at a sixth grade reading level.  Providing clear contact information and encouraging patients to call their nurse or doctor with any questions about discharge instructions could also improve the follow-up care patients are receiving.

Root Cause Analysis

Patient Discharged Alone, Without Being Treated

By ThinkReliability Staff

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”.