Tag Archives: fatalities

Root Cause Analysis

Multiple Factors Contributing to Health Care Crisis in Venezuela

By ThinkReliability Staff

Venezuela is facing a health care crisis of massive proportions. Since 2012, the infant mortality rate has skyrocketed from 0.02% to more than 2%. (The latest numbers are from 2015, so this is a hundred-fold increase within 3 years.) The mortality rate for new mothers increased almost 5 times over the same period. Everyone else isn’t doing too well either. Says Dr. Yamila Battaglini, a surgeon at J. M. de los Ríos Children’s Hospital, “There are people dying for lack of medicine, children dying of malnutrition and others dying because there are no medical personnel.” That doesn’t even cover all of the problems facing Venezuela right now, which include:

Rolling blackouts: The government has announced official “rolling” blackouts of at least 40 days. That includes hospitals and other medical facilities. (Doctors are reporting having to work in the dark.) At least one hospital has a generator that doesn’t work. One reason electricity is being rationed is that even though money has been allocated to building new power plants, the plants aren’t online, and the money hasn’t been accounted for. (Unfortunately this kind of potential theft/ corruption is much too common in Venezuela). Another reason is . . .

Drought: The Guri hydroelectric dam provides 75% of the nation’s electricity, and currently has extremely low levels due to drought. The drought, caused by El Niño, has also resulted in a general lack of water, which is now being rationed. The combination means that the hospital doesn’t have adequate water supplies, resulting in . . .

Lack of sanitation: Without water, sanitation suffers. Doctors have reported performing surgery after a quick rinse from a water bottle, and no rinsing down of surgical beds or instruments before the next surgery, or procedure. But the people who are getting surgery or procedures are lucky, because many hospitals are also suffering from . . .

Shortages of medical personnel: Many medical professionals have left Venezuela during the severe ongoing economic issues (such as inflation, currently pegged at 700%) due to both the decreasing price of oil (Venezuela’s main export) and what have been called “disastrous” government policies. Says Ricardo Hausmann, Professor at the Kennedy School of Government (and Venezuela native), “Venezuela’s problems are a consequence of the craziest economic policy ever in a country or in the world. It’s a country that has gone through its longest and highest oil boom in its history, and ended that period over-indebted, with a destroyed productive capacity, and now it cannot face the reduction in the price of oil.” Doctors that remain face exhaustion – without water and power, many are attempting to save lives by manually operating equipment (such as respirators for newborns). Even this can’t save lives with . . .

Shortages of drugs and equipment: The Pharmaceutical Federal of Venezuela estimates that the country is lacking ~80% of needed basic medical supplies. Price controls in Venezuela resulted in official selling prices lower than manufacturing costs. This made it financially infeasible to provide many products. The government can’t afford to import drugs, and individuals have difficulty doing so because official currency exchange isn’t available. (Even if it was, Venezuelan money is virtually worthless at this point, as the government keeps printing more.) Theft and corruption have also resulted in the loss of some equipment. And as if this all weren’t enough, the country is also suffering from . . .

Zika outbreak: To a country that lacks almost all ability to provide health care, add an ongoing outbreak (see our previous blog) for which there is currently no cure, and you end up with a situation where “some come here healthy, and they leave dead.” (Dr. Leandro Pérez, Luis Razetti Hospital)

With this many (and this severe) problems, there are no easy answers. Making the situation even worse is the government’s denial that there IS a problem. Says President Nicolás Maduro, “I doubt that anywhere in the world, except in Cuba, there exists a better health system than this one.” This is preventing other countries from providing aid, sometimes because they are unaware the extent of the need. At least one country, India, is offering drugs for oil, though that may be mainly to recoup funds they are already owed, not for providing new medication.

In order to see the multitude of causes that have resulted in the health care crisis in Venezuela laid out in a visual cause-and-effect format, click on “Download PDF” above. Or click here to read more.

Root Cause

Care Home Residents Unable to Escape Fire

By ThinkReliability Staff

A tragic fire at a care home for residents dependent on caregivers occurred in Pingdingshan, China on the night of May 25, 2015. Of the 51 residents housed at the 130-bed care home, 38 were killed and 6 injured.

It is tempting to declare the fire as the “root cause” of the tragedy. However, doing so limits the analysis (and thus potential solutions) to only prevention of fires. While many potential improvements in fire prevention at this and other structures with high-risk occupants can be identified, it’s also important to identify solutions that increase the probability of occupants being able to successfully escape a fire.

To ensure that the investigation develops the broadest possible range of solutions, begin with the impact to the goals. In this case, the primary goal impacted was that of resident safety – 38 residents died and 6 were injured. Most residents were unable to escape, impacting the resident services goal. The care home was completely destroyed, impacting the property goal, and it was found to not meet standards, impacting the compliance goal.

Once we’ve determined the impact to the goals, we can develop a Cause Map, or a visual diagram of cause-and-effect relationships that led to the impacted goals. Beginning with one of the impacted goals (in this case the deaths and injuries), and asking “Why” questions develops the cause-and-effect relationships. In this case, the deaths were due to the severe fire at the care home. But that isn’t the only cause. After all, the fire occurred in a facility where 51 residents were (presumably) sleeping, and there were a few residents who were able to escape with their lives.

This means that the cause-and-effect relationship of “fire kills resident” is accurate, but not complete. The effect of the deaths resulted not only from the fire, but from the residents being unable to escape. This gives us two different lines of questioning and possible solutions.

A severe fire results from a fire being initiated and spreading. Heat, fuel and oxygen are required in order to initiate a fire. Oxygen is present in the atmosphere. As in most fires due to destruction of evidence, the heat (or ignition) source has not been identified, but the national work safety agency investigation did find “irregularities” in the electrical system, which could be a potential source. While the initial fuel source is not clear, the care home was constructed with highly flammable materials, which allowed the spread of the fire.

The residents in the care home were dependent on caregivers and so were generally unable to escape without help. Unfortunately help was in short supply. Although residents complained of a shortage of caregivers, it’s not clear how many caregivers were on duty at the time of the fire. Shortage of caregivers is a huge problem in China due to the large percentage of the population that is older, which resulted from the one child policy of previous generations. It’s estimated there are 200,000 caregivers for the elderly in China, and 10 million are needed. In addition, the national work safety agency investigation found that the escape routes in the care home were poorly designed, making it difficult for anyone to escape.

After the tragedy, Chinese Premier Li Keqiang called on others to “draw lessons from the accident, checking all potential safety hazards to avoid similar incidents.” To avoid deaths from fire, that involves not only reducing the risk of fire, but making sure all people, regardless of ability, are able to escape.

To view the analysis of this issue, click on “Download PDF” above. To read about an arson at a care home in Australia that killed 11 and spurred a law requiring installation of automatic sprinkler systems, click here.

 

Root Cause

Safely using a treadmill is not quite as simple as it seems

By Kim Smiley

Did you know that treadmills are the riskiest exercise machines?  I sure didn’t, but I have to admit that I have fallen off one before.  (Based on conversations with my coworkers, this isn’t all that uncommon.)  As recent headlines have made clear, using a treadmill safely may not be quite as simple as it seems.

According to data from the National Electronic Injury Surveillance System, about 19,000 people went to the emergency room (ER) because of treadmill injuries in 2009, which is about triple the number of injuries reported in 1991.  More and more people are using treadmills and the number of accidents has increased as well. Although only a small percentage of the injuries are serious, about 30 deaths related to treadmill use were reported between 2003 and 2011.

Understandably, the details surrounding Dave Goldberg’s death have not been released to the public, but it is believed that he slipped while using a treadmill and hit his head when he fell.  Falls off treadmills that result in serious injury are rare, but they have the potential to cause significant injury and even death. More common injuries associated with treadmill use are less serious overuse injuries, such as strains and sprains.

Children are at particular risk of being injured by treadmills.  A motor propels the belt on treadmills and children can get their extremities caught in the moving belt or suffer burns if they accidently turn a treadmill on or one is left running while unattended.  Of the 19,000 ER visits associated with treadmills in 2009, nearly a third were for children under age 9.

So how do you stay safe while using a treadmill?  The number one rule is to limit distractions.  Using a phone or watching TV puts you at a much higher risk of accidently misplacing a foot and falling.  (Trying to write an email while I walked on a treadmill is what resulted in my own fall.  Luckily, only my pride was injured, but I have learned my lesson.)

Treadmills have also risen in complexity and all the buttons and options can be distracting, especially if you are unfamiliar with the specific equipment.  Make sure you understand how to use the treadmill prior to starting the belt.  If you have balance issues or are elderly, you should also check with a doctor prior to using a treadmill.  And lastly, start by walking slowly and gradually increase the pace of the treadmill so that you aren’t caught unaware by how quickly the belt is moving.

To view a Cause Map of this issue, click on “Download PDF” above.

Root Cause

Listeria in Ice Cream Causes 3 Deaths

By ThinkReliability Staff

On April 20, 2015, the Centers for Disease Control and Prevention (CDC) announced a recall of all Blue Bell Creameries products due to possible contamination by Listeria monocytogenes.  While the company has not yet determined the source of the outbreak, they are working with outside agencies to determine potential causes and implementing solutions to reduce the risk of food-borne illness in the future.  Says Paul Kruse, the CEO and president, “We’re committed to doing the 100 percent right thing, and the best way to do that is to take all of our products off the market until we can be confident that they are all safe.  At this point, we cannot say with certainty how Listeria was introduced to our facilities and so we have taken this unprecedented step.  We continue to work with our team of experts to eliminate this problem.”

Performing a root cause analysis can help clarify the goals of an investigation, determine the causes of the problem(s) related to an issue, and provide ideas for action items to reduce the risk of the issue recurring.  We can gather the information known so far about the outbreak in a Cause Map, or visual root cause analysis.

The Cause Mapping process begins by capturing the what, when and where of an incident.  Here, the “what” is the Listeria outbreak.  The “when” in this case is believed to have started in 2010 and continued to the present.  It can be helpful to capture any noted differences about the particular investigation.  For example, most outbreaks don’t last 5 years.  The use of genome sequencing (starting in 2013) allowed investigators to tie Listeria cases from 2010 on to this particular outbreak.  An additional difference is that Listeria can replicate in very cold temperatures.  This is unusual because freezing foods generally reduces the risk of propagating food-borne contamination.  The “where” is across the US – all products have been recalled and all plants have been shutdown, with several having been implicated in spreading Listeria.  Another useful piece of information can be the task being performed.  In this case, the contamination was discovered during random sampling.

The next step is identifying the impacts to the goals.  For this incident, the safety goal was impacted due to the sicknesses and deaths.  The outbreak of Listeria can be considered an impact to both the environmental and customer service goal, while the loss of production (no Blue Bell products are currently available or being produced for consumers) is an impact to the production goal.  The disposal of the estimated 8 million gallons of ice cream covered by the recall impacts the product goal, and the response and investigation impacts the labor goal.

The analysis step begins with an impacted goal.  Asking “why” questions develops the cause-and-effect relationships that led to the impacts.  In this case, the sicknesses and deaths were caused by a Listeria outbreak.  In order to have a food-borne illness outbreak, the food needs to be contaminated AND it needs to be delivered to consumers.  In this case, the contamination was not known because ice cream is not tested for Listeria.  There is no history of Listeria outbreaks in ice cream and testing is difficult on perishable products because of the time required.  Once ice cream products are again manufactured for consumers, Blue Bell has said it will implement a test and hold process (holding product until testing comes back negative).

The Listeria contamination results from the introduction of Listeria into the ice cream.  As discussed before, Listeria can replicate in cold temperatures.  The contamination source is likely surfaces in the production facilities or cross-contamination from other food products.  Because multiple plants are contaminated and cleanliness issues have been a concern in the past, it is likely that the outbreak is due to contamination of surfaces, on which Listeria can remain for a long time if not properly sanitized.

In addition to the test and hold process, Blue Bell is in the process of implementing a number of other changes to reduce the risk of future contamination.  Employees are being trained in microbiology and an expanded cleaning and sanitation program.  Prior to production resuming, equipment is being disassembled, cleaned, and tested for contamination and design changes that would make cleaning easier (reducing the risk of future contamination) are being considered.

While it is sometimes difficult to determine the success of solutions, the test and hold process to be used for future ice cream products should provide almost real-time feedback on the success of the programs and ensure that future problems are quickly identified.

To view a one-page PDF of the analysis and solutions, please click on “Download PDF” above.  To learn more about the ice cream Listeria outbreak, click here.  To read our previous blog about the 2011 fatal Listeria outbreak in cantaloupe, click here.

Root Cause

Hospital Admits Fault, Implements Improvements after Death due to Medication Error

By ThinkReliability Staff

A hospital in Oregon administered the wrong medication to a patient who stopped breathing. Because of a fire alarm that happened shortly afterwards, the patient was not monitored for about twenty minutes. After that time the patient had experienced irreversible brain damage and was taken off life support on December 3, 2014.

In a surprising move, the hospital has taken responsibility for the error. Dr. Michel Boileau, the chief clinical officer, has stated, “We do know there was a medication error. We acknowledge that. It’s our mistake.” While an Oregon law, which took place in July, encourages transparency with patients and loved ones and reporting in the case of medical errors, the hospital says communication in the case of errors has been its practice for years and that it’s the right thing to do.

Supporting the transparency, the victim’s son says, “We want the community to know what happened. Precautions need to be taken. The only message we really have is that life is short and you never know when something like this could happen.”

Detailed information regarding the case has been released in the media. Using that information, it is possible to put together a Cause Map showing the cause-and-effect relationships that led to the death, and show how the hospital’s planned improvements address the causes.

In this case, administration of the paralyzing agent Rocuronium instead of the prescribed anti-seizure medication fosphenytoin caused the patient to stop breathing, leading to cardiac arrest and irreversible brain damage. Monitoring of the patient may have caught the lack of oxygen prior to irreversible damage, but in this case the patient was not monitored. Shortly after the administration of the IV, the hospital experienced a fire alarm (“code red”), at which point staff left the patient’s room and closed her door. Staff estimates she was unmonitored for about twenty minutes.

Medication errors that happen within hospital facilities almost always involve an error in the medication process. As part of the investigation, Dr. Boileau states, “We’re looking for any gaps or weaknesses in the process, or to see if there has been any human error involved.” So far the hospital has determined that the IV bag given to the patient was filled with the wrong medication at the in-patient pharmacy but then coded for the correct drug. It’s unclear exactly what happened at the pharmacy, but there was either no check of the medication filling or the check was ineffective, as it allowed the wrong drug to be delivered to the patient for administration.

According to the hospital’s chief nursing officer, Karen Reed, “We are all committed to honoring Ms. Macpherson’s name by learning everything there is to learn here and making sure no other patient has to go through this again.” While the investigation into the details continues, the hospital has already planned some improvements to work towards that goal.

To reduce the risk of medication errors, the hospital is designating a safe zone to be used for medication verification. (Distraction has been shown to be a primary driver of medication mix-ups.) They’re also reviewing and updating their medication protocols and ensuring that a detailed checking process is implemented. Because of the particular danger associated with mistakes involving paralyzing agents (like Rocuronium), alert stickers have been added to these types of drugs. Because of the issues with patient monitoring, procedures that ensure patient monitoring after IV administration (presumably even in the case of an unusual event or emergency) will be implemented.

What does this mean for you? Medication errors are considered rare, but even one is one too many. Medication administration processes at healthcare facilities must be designed to minimize the risk of error by reducing interruptions and ensure double checks. Other guides, such as alert stickers, can be used to emphasize particular risks (not limited to medication errors). In healthcare facilities (or any other facilities where operations can’t safely be put “on hold”), there needs to be a plan for ensuring that necessary tasks are performed, even with emergency or unusual situations.

Read more about this incident.

Learn more about medication errors.

Root Cause

Lethal injection fails to quickly kill prisoner

By ThinkReliability Staff

While the use of the death penalty remains highly controversial, there is general agreement that if it is used, it should be humane.  The execution of a prisoner in Oklahoma on April 29, 2014 did not meet those standards.  The inmate died 43 minutes after the drugs were injected.  (Typically death takes 5-6 minutes after injection.)  According to Jay Carney, the White House Spokesperson, “We have a fundamental standard in this country that even when the death penalty is justified, it must be carried out humanely – and I think everyone would recognize that this case fell short of that standard.”

The details surrounding this case can be captured in a Cause Map, or visual root cause analysis, to examine the causes and effects of the issue.

The problem being evaluated is the botched execution of an inmate in the Oklahoma State Penitentiary. The execution began at 6:23 pm on April 29, 2014.  An important difference in this execution, compared to other executions, is that it was the first time the state had used the drug midazolam as part of the three-drug injection protocol.  The protocol, when originally developed in 1977, called for sodium thiopental, followed by pancuronium bromide and potassium chloride.

The safety goal was impacted in this case because of the failed execution.  The public service goal can be considered to be impacted as the execution was called off (after all three drugs were administered; the prisoner later died of a heart attack.)  The schedule goal is impacted because all future executions have been called off.  The state planned a two-week postponement of the next execution (scheduled for later the same day) in order for a review of this investigation to be completed, but at the time of this writing, that execution has not yet been scheduled.  Executions across the country have been appealed or stayed and none have taken place since April 29th.  The labor/ time goal is also impacted due to the investigation into the execution, which has not yet been published.

These goals were impacted due to the failure of the lethal injection.  The process intended to be used for this lethal injection is detailed on the downloadable PDF.  However, from the start things didn’t go smoothly.  Instead of using two IVs, one in each arm, only one IV was able to be connected, in the patient’s groin.  Because sodium thiopental is no longer available (drug companies will no longer provide it for use in lethal injections), the drug midazolam was used instead.  However, the protocol for using that drug is disputed.  In Florida, five times the amount of midazolam is used.  In Oklahoma, midazolam is used along with hydromorphone.  Because of the debate about lethal injection, most states don’t divulge their suppliers, so the efficacy of the drugs used cannot be verified.  In addition, there is generally at least one doctor present to oversee the executions, but these doctors are not usually identified and may not participate in the actual administration of the drugs because many medical organizations ban doctors from participating on ethical grounds.

At this point, it’s unclear what will happen at future executions.  The investigative report being prepared by the state of Oklahoma may give some suggestions as to how to make lethal injections more humane in the future, or this may tilt the scales towards ending lethal injection, or executions altogether.

To view the Outline, Cause Map, and Process Map, please click “Download PDF” above.

Root Cause

Increase in Resistant Bacteria and Fungus Threatens Public Health

By ThinkReliability Staff

On September 16, 2013, the Centers for Disease Control and Prevention (CDC) issued a report “Antibiotic Resistance Threats in the United States, 2013”.  This report detailed the impacts, causes and recommended solutions related to antibiotic resistance within the US (although the concerns are similar worldwide).

The report takes the form of an incident investigation.  Specifically, the report addresses the impacts to the goals of the CDC, the cause-and-effect relationships resulting in these impacts, and what is recommended to reduce the risk of these impacts continuing. The information presented in their report can be captured in a Cause Map, or visual root cause analysis, which allows a demonstration of the interaction of the various causes presented in the report.

The report begins with the goals being impacted by the problem of antibiotic resistance.  Specifically, the CDC conservatively estimates that more than 2 million people are sickened in the US every year by antibiotic-resistant infections.  More than 23,000 are estimated to die as a result.  The risk is not just for the general public, but healthcare providers as well, who are implicated in the report as having resistant strains on their hands, which causes a health risk for them as well as patients.  The report identifies not only person-to-person spreading of infection, but also spreading from environmental causes, such as food.  The presence of these strains impacts the environmental goal as well.

The cost of these infections is staggering.  It is estimated that up to $20 billion per year is spent on direct excess healthcare costs as a result of these infections in the US alone.  The productivity cost (loss of productivity across industries due to employees being out sick) is estimated to be as high as $35 billion per year.  (While the causes discussed in the report are of concern globally, the impacts to the population are specific to the US.)

Increased illness from resistant infections results from exposure to resistant infections, decreased protection from infection, and a shortage of drugs available to treat these infections.  Exposure to antibiotic-resistant infections results from either person-to-person or environmental spread.  Spread can pass from anybody who has antibiotic resistant bacteria or fungus, but a primary source is healthcare providers, who can easily pass the infection with improper hand washing (or none at all).  Environmental causes include surfaces (again, healthcare providers are a frequent source here) but also food.  Food animals are given antibiotics to control disease, but also sometimes are given antibiotics without a diagnosis to prevent infection or promote growth.  These antibiotics kill off non-resistant bacteria but not resistant bacteria, which remains in the meat and feces.  If meat is improperly cooked, the bacteria can be passed on to humans.  But the issue is not just with improperly cooked meat.  Other foods can be contaminated with animal feces, which can also contain the resistant bacteria.

When a person is taking antibiotics, they have a decreased protection from infection.  This is because antibiotics kill all bacteria – including “good” bacteria that helps prevent infection.  While antibiotics are used to treat disease,  the CDC estimates that 50% of prescriptions are unnecessary or not optimally effective.  The use of antibiotics has been identified as the single most important factor leading to antibiotic resistance.

The increase of antibiotic-resistant bacteria (and fungi) means that more and more drugs are becoming ineffective in treating these infections, increasing the risk of death when infections occur.  Additionally, research and development into antibiotics is slowing, compounding the problem of effective drug availability.

As part of the report, the CDC provides wide-ranging recommendations to limit antibiotic-resistant infections.  The recommendations are for healthcare providers, communities and individuals.  They aim to first prevent the spread of infection by ensuring that antibiotics are prescribed and used properly, as well as by better tracking the spread of antibiotic resistant pathogens.  This includes stopping the use of antibiotics in feed animals for growth promotion.  Additionally, better cleanliness control for healthcare providers, food preparers and the general population will reduce the spread of disease.  Secondly, the CDC aims to provide better treatment for these infections by investing in research and development to provide new antibiotic treatment options.  It is also hoped that surveillance data can provide more effective diagnostic tools and use of the treatments currently available.

To view the Outline and Cause Map, please click “Download PDF” above.

Want to learn more?
Read the CDC report.
Read our previous blog on Carbapenem-Resistant Enterobacteriacae (one of the “Urgent” threats identified in the CDC report).

Root Cause

Common Birth Control Pills Have Increased Risk of Blood Clots

By Kim Smiley

Deaths of 24 Canadian women associated with the use of Yaz and Yasmin birth control pills have been making headlines in recent weeks.  South of the border in the US, more than $1 billion has already been paid out to settle thousands of lawsuits over alleged side effects.  Yaz and Yasmin are drospirenone-based birth control pills that are the most widely prescribed birth control pills worldwide so any concerns with the safety of the medication are alarming.

This issue can be analyzed by building a Cause Map, or visual root cause analysis.  A Cause Map lays out the many causes that contribute to an issue in an intuitive way that illustrates the cause-and-effect relationships.  The first step in the Cause Mapping process is to fill in an Outline with basic background information and to determine how the problem is affecting the overall goals of the organization.  In this example, side effects from the pills have been reported to have caused deaths and injuries.    Lawsuits associated with the side effects, specifically blood clots, have cost the drug manufacturer huge amounts of money as well as generated significant negative publicity, neither of which are outcomes a company is hoping for.

The complaints about severe and potentially deadly side effects have been focused on blood clots.  Blood clots are a known potential side effect of using any birth control pills.  It is believed that the estrogen used in birth control pills increases the clotting factors in blood making blood clots more likely.  The reason these specific pills are making headlines is that researchers have found that drospirenone-based birth control pills have a higher risk of blood clots than other birth control pills.  Researchers have estimated that the risk of blood cloths is 1.5 to 3 times higher with drospirenone-containing pills than with some other birth control pills.

For perspective, the FDA has stated that if 10,000 women who are not pregnant and do not use birth control pills are followed for one year, between 1 and 5 of these women will develop a blood clot and for women using birth control pills the range is 3 to 9.  But, and in my opinion this is a pretty big but, it’s worth knowing that the risk of blood clots during pregnancy is estimated to be 5 to 20 out of 10,000 and it’s even higher during first 12 weeks postpartum; estimated to be 40 to 65.

Please talk to your doctor if you have any concerns about blood clots or questions about whether a particular birth control pill is safe for you, especially if you think you may have other risk factors for blood clots.  If you’re curious about the symptoms of a blood clot or about other risk factors you can get more information here.

Please click on “Download PDF” above to see a high level Cause Map of this issue.

Root Cause

11 Patients Killed in Nursing Home Fire

by ThinkReliability Staff

A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia.  At least 11 residents died as a direct result of the fire and nearly 100 were evacuated.    A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)

The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson.   The reasons for the arson are unclear and may never be fully understood.  However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.

We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy.  We begin the analysis with the “What, When and Where” of the event, captured in a problem outline.  Additionally, we capture the impacts to an organization’s goals.   In this case, the patient safety goal was impacted due to the deaths.  There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder.  Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million.  (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.)  Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.

Capturing the  frequency of similar issues can help provide perspective on  the magnitude of nation and world-wide issues.  I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year.  There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.

Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts.  In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility.  The fire initiation, as discussed above, is believed to be due to arson.  However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.

Studies after the event showed how critical sprinklers can be to slow the spread of a fire.  On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016.  It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.

To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.

Root Cause

Cases of Deadly ‘Superbugs’ on the Rise in US

By Kim Smiley

A new antibiotic resistant strain of bacteria is causing deaths and raising flags in US healthcare facilities. The bacteria is called Carbapenem-Resistant Enterobacteriaceae, often shortened to CRE, and is named for its ability to resist carbapenem antibiotics, the last resort treatment for antibiotic resistant bacteria. The fatality rate for those infected may be as high as 50 percent. In 2012, 4 percent of hospitals reported cases of CRE, up from about 1 percent a decade ago. The situation at long-term care hospitals is significantly worse, with 18 percent reporting cases last year.

The issue of CRE can be analyzed by building a Cause Map, a visual method for performing a root cause analysis. The first step is to create an Outline that documents all the background information for an issue. How the problem impacts the overall organization goals is also listed on the bottom of the Outline. In this example, the safety goal is obviously impacted since there have been patient deaths. After the Outline is completed, the second step is to build the Cause Map. The Cause Map is built by asking “why” questions to determine what causes contributed to the issue and then arranging the causes visually to show cause-and-effect relationships. Why have there been patient deaths?  This has occurred because they were infected with CRE and CRE infections are dangerous.

People are being exposed to CRE primarily in healthcare settings. CRE is being passed between patients within the same facility and between healthcare facilities as infected patients are transferred to different healthcare settings. Exposure is occurring between patients because infected patients may not be identified or adequately isolated. Many healthcare facilities do not have the capability to test for CRE and it’s also difficult to identify who should be tested since some patients who carry the bacteria are not symptomatic. CRE also tends to infect individuals who have other health issues and weakened immune systems. Treatment of the other issues may involve invasive medical devices, such as catheters, that can provide a pathway for infection into the body.

CRE infections are dangerous because they have a high rate of fatality, up to 50 percent according to the CDC, and they are difficult to treat. CRE are resistant to virtually all antibiotics. This strain of bacteria is also particularly worrying because they can transfer their resistance to other bacteria within their family, compounding the problem. Antibiotic resistant bacteria have developed over the years because of the wide use of antibiotics. Each time antibiotics are used, bacteria have a chance to evolve and they have over the years.

The final step in the Cause Mapping process is to find solutions that would reduce the risk of the problem in the future. In this example, there isn’t an easy solution. There are no promising new antibiotics in development at this time that would likely be able to treat CRE infections so the best hope is to prevent the bacteria from spreading. The CDC has recommended steps such as identifying and isolating infected patients.

This example also show important it is to track the effectiveness of solutions after they are implemented because there can be unintended consequences that show up later on. Antibiotics have saved thousands of lives, but they are becoming less effective as bacteria develop resistance to them. New solutions will be needed to prevent or fight these types of infections in the future. Cause Mapping is a useful tool to document evolving issues because they can easily be adjusted and added to as new information is available.

To view a high level Cause Map, click on “Download PDF” above.