Tag Archives: safety

Root Cause

Explosion, Deaths at Maternity Hospital Follow Gas Leak

By ThinkReliability Staff

A gas tanker was providing fuel to a maternity hospital in Mexico City when the gas workers discovered a leak. They contacted the fire department, had the hospital evacuated, and attempted to put out the leak. Unfortunately, the leaked gas exploded, killing at least 2 nurses and 2 babies, and leveling most of the hospital.

Dozens more infants, patients and nursing staff were injured, along with the three gas workers present at the scene. The gas workers have all been arrested, though the charges against them have not been released. While it appears that the workers are being held responsible for the tragedy, providing an objective, factual analysis as to what happened can provide useful information to reduce the risk of the issue happening again.

When performing a root cause analysis of an issue (as we will do here in a Cause Map), it’s important to first capture the impacts to the organizational goals as a result of the incident being investigated. In this case, the patient safety goal is impacted because of the deaths of two infants and the injuries to dozens of patients. The safety of hospital employees was impacted due to the deaths of two nurses and injuries to many more. Additionally, the safety of the gas company employees was impacted because all three of the gas workers were injured.

The environment was impacted due to the gas leak. The compliance goal was impacted because the three workers were arrested. The patient services and operations goals were impacted by the evacuation from the hospital (which is very difficult on patients and staff, although it likely saved many lives in this case). The property goal is impacted because of the severe damage to the hospital and the labor goal is impacted by the rescue efforts. (Hospital neighbors are reported to have provided considerable assistance to the rescue efforts at no small risk to themselves.)

Any time deaths or injuries result from an explosion, it is important not only to determine what caused the explosion, but whether the response could have been improved. In this case, the explosion occurred while the hospital was being evacuated, though a specific timeline of the leak, evacuation and explosion has not been released. Further analysis into the evacuation will help determine whether improvements could have saved lives.

In the case of the explosion, the fuel was provided by the leaked gas. Adequate oxygen was present in the air, and the ignition source (heat) could have been provided by hospital operations (the gas was being delivered near the hospital kitchen) or potentially by work being done to repair the leak (such as static or a spark). The gas leaked due to a faulty gas delivery hose. When a faulty part contributes to a tragedy such as this one, it’s important to determine not only how the damage occurred (if possible), but whether inspections or maintenance could have reduced the risk of an incident. Clearly if the hose had been discovered to be faulty and replaced before the delivery took place, the risk of an explosion would have been greatly decreased.

A broader issue for the entire country is the question of why gas leaks and explosions are fairly common. Part of this is because there is no infrastructure to pipe gas underground and it instead has to be delivered by truck. A similar incident involving a hose issue on a gas truck killed three in Queretaro in July last year. The company that provided the gas to the hospital in this case says that it has 1,000 trucks that deliver gas to over 80% of the country. With such a large distribution network, accidents are bound to happen. However, clearly more effort needs to go into making sure that the impact on human lives is reduced.

Root Cause

US Doctors Issue Statement That Mothers Should Avoid Water Births

By Kim Smiley

The number of water births in the United States has been increasing in recent years and controversy over their safety continues to rage.  The latest development is that the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recently issued a joint statement saying that water births are not recommended and should be avoided, but some midwives and mothers disagree and adamantly defend the benefits of birthing in water.  The doctors agree that soaking in water during early labor may make the experience more pleasant for mothers, but feel that actual birth should be outside of the birthing tub.

One of the issues is that the benefits of water birthing are difficult to prove and the potential risks are difficult to quantify .  Some mothers believe that birthing in water helps relieve pain and can aid in a drug-free delivery.  Supporters of the practice also think that birthing in water can shorten labors, which reduces stress on the mother and the baby.  Some midwives have also expressed a belief that water births are gentler on babies, saying that many do not cry when they are born.  It’s difficult to definitively study the impacts of water births because birth outcomes depend on so many factors and you can’t do a double-blind study because it’s pretty much impossible to have a placebo for a water birth.

There have been reports of individual cases where something went wrong during a water birth, but there is little information on how often this occurs.  There is general agreement that complications are rare, but the doctors  releasing the statement feel the risk of complications outweighs the benefits.  The most serious concern is the baby drawing its first breath underwater, which could lead to breathing issues and even drowning.  There is also a risk of umbilical cord ruptures since the baby must be brought to the surface relatively quickly and the cord may be too short.  There is also increased risk of infection for the mother and baby since they are both exposed to potentially contaminated water because birth can get messy.

Until now, there has been little formal guidance provided about water births.  Providing more information for expectant mothers is a great first step, but disagreement between medical professionals about birthing methods can add confusion to an already stressful time.  Until more studies are done to provide a better understanding of the risks involved, women will have to rely on their own judgment and the guidance of their healthcare provider.

To view an Outline and Cause Map of this issue, please click “Download PDF” above.

Root Cause

The Willie King Case: Wrong Foot Amputated

By Kim Smiley

In one of the most notorious medical error examples in US history, the wrong foot was amputated on a patient named Willie King on February 20, 1995.  Both the hospital and surgeon involved paid hefty fines and the media had a feeding frenzy covering the dramatic and alarming mistake.

So how did a doctor remove the wrong foot?  Such a mistake seems difficult to comprehend, but was it really as mind boggling as it looks at first glance?

The bottom line is that the doctor honestly believed he was removing the correct foot when he began the surgery. The blackboard in the operating room and the operating room schedule all listed the wrong foot because the scheduler had accidentally listed the wrong foot.  After reading the incorrect paperwork, the nurse prepped the wrong foot.  When the doctor entered the operating room, the wrong foot was prepped and the most obvious documentation listed the wrong foot.  Basically, the stage was set for a medical error to occur.

The foot itself also looked the part.  The patient was suffering from complications of diabetes and both of his feet were in bad shape.  The “good” foot that was incorrectly removed looked like a candidate for amputation so there were no obvious visual clues it wasn’t the intended surgery site. Other doctors had testified in defense of the doctor saying the majority of other surgeons would have made the same mistake given the same set of circumstances.

There was some paperwork that listed the correct foot to be amputated, such as patient’s consent form and medical history.  This paperwork was available in the operating room, but no procedures in place at the time required the doctor to check these forms and these forms were far less visual than the documents where the incorrect information was listed.  Additionally, the doctor never spoke directly with the patient prior to the surgery which was another missed opportunity for the mistake to be caught.

Clearly the procedures needed to be changed to prevent future wrong site surgeries from occurring and a number of changes have been incorporated in the time since this case occurred to help reduce the risk of this type of medical error.  Surgeons in Florida are now required to take a timeout prior to beginning a surgery.  During the time out they are required to confirm that they have the right patient, right procedure and right surgical site.  This rule has been in place since 2004.

Mistakes will always happen, such as numbers being transposed or misheard words over the phone, but small mistakes need to be caught before they become big problems. Procedures like a timeout can significantly reduce the likelihood of an error going uncorrected.  In an ideal world, the simple mistake by the scheduler would have been caught long before it culminated in a surgery on the wrong body part.

A visual root cause analysis, called a Cause Map, can be built to illustrate the facts of this case.  A Cause Map intuitively lays out the cause-and-effect relationships including all the causes that contributed to an issue.  To view a Cause Map of this example, click on “Download PDF” above.

Root Cause

National Effort Improves Cardiac Arrest Survival Rates

By ThinkReliability Staff

October is Sudden Cardiac Arrest (SCA) Awareness Month.  In Northern America, more than 300,000 people are affected every year by out-of-hospital SCA, which occurs when the heart no longer beats properly.  According to the American Heart Association, about 92% of SCA victims die before reaching the hospital.

Survivability of SCA is dependent on the length of time between SCA and chest compressions that allow blood flow to the heart and brain.  This can be accomplished by non-medical personnel using Cardiopulmonary Resuscitation (CPR), known as “bystander CPR”, which can provide lifesaving treatment for a victim of SCA until medical personnel arrive.

In Denmark, the rate of patients who received bystander CPR in 2001 was 21.1%.  The country embarked on a national initiative to improve SCA survivability.  This initiative included increased training of residents as early as elementary school.  Instructional kits were provided, and learning CPR was required in order to receive a driver’s license.  The percent of patients who received bystander CPR increased from 2001 to 2010 to 44.9%.

In addition to the increased education of the general population about CPR, changes were made to improve care provided after SCA by hospitals and emergency medical services.  According to a study in the Journal of the American Medical Association, these changes together have improved the survivability of all stages after SCA.  From 2001 to 2010 in Denmark, cardiac arrest patients arriving at a hospital alive increased from 7.9% to 21.8%.  In addition, 30-day and 1-year survival also increased, from 3.5% to 10.8% and 2.9% to 10.2%, respectively.

Denmark’s initiative hopes to lessen the reluctance bystanders may have to perform CPR due to lack of training.  In addition, the American Heart Association recommended in 2008 that laypersons perform compression-only CPR (no breaths) if they are unable or unwilling to provide rescue breaths.  This may have also decreased the reluctance of bystanders to perform CPR due to concerns about spread of disease, or feeling uncomfortable giving rescue breaths.

Providing additional training to emergency medicine providers can also improve survivability.  Another recent study by the University of Arizona has found that improving the quality and effectiveness of CPR performed by emergency medicine providers improved survival rates.  In the study, rescuers were provided real-time feedback as to the quality of the CPR being provided, as well as training that emphasized a team approach.  Before these interventions, 26% of SCA victims survived to hospital discharge.  After the interventions, 56% of victims survived to discharge.

Although CPR dates back to 1740, improvements in availability and quality are still being found that can increase survivability of SCA victims.  Because of the importance in quick and effective action, the importance of action by non-medically-trained bystanders to the survival rate after SCA provides strong support for layperson CPR training.

To view the Outline and Cause Map including the cause-and-effect of the improvements to survival rate in Denmark as a result of interventions and improvements, please click “Download PDF” above.

Root Cause

RISK: Vaccines vs. Disease

By ThinkReliability Staff

Although endemic transmission of measles has been considered “interrupted by vaccination” in the United States, a recent measles outbreak has brought to the forefront the risks of not getting vaccinated.  A member of a church in Texas, who had not received the full measles vaccination, traveled to Indonesia, an area where measles is still endemic.  The disease, which is easily spread in close contact, then infected at least 20 other members of his church, which has concerns about the risks of vaccination, especially bundled vaccinations like the MMR (measles/ mumps/ rubella) vaccine.

In recent years, people have been increasingly concerned about the risks of vaccination.  One of the main concerns with the MMR vaccine is its purported link to autism (which was first mentioned in a 1998 study that has been mostly discredited).  There are, of course, risks to vaccination for any disease.  According to the CDC, risks from the MMR vaccine include mild problems, such as fever (up to 1 person out of 6), mild rash (up to 1 person out of 20) and very rare severe problems, such as allergic reactions (which occur in less than 1 out of a million doses).

However, as the CDC notes “The risk of the MMR vaccine causing serious harm, or death, is extremely small.  Getting the MMR vaccine is much safer than getting measles, mumps or rubella.”  This brings us to the other side of the equation.  People who do not get vaccinated for these diseases face the risks of getting the disease.  According to Dr. Paul Offit, Chief of the Division of Infectious Diseases and Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, “There are only two ways you can develop specific immunity, either be infected by the natural virus or be immunized.  A choice not to get a vaccine is not a risk-free choice, It’s a choice to take a different and more serious risk.”

Because transmission of measles had been considered effectively stopped in the US, not vaccinating may have seemed like a minor risk.  After all, there are some people who cannot receive the vaccine.  This includes young children, pregnant women, and those who may be suffering from other health concerns.  These people have generally been protected by “herd immunity”.   This refers to the unlikelihood of getting measles when a very high percentage of the population is vaccinated against it.

However, in recent years, the number of people choosing not to get vaccinated has been increasing.  Sometimes these people are clustered geographically, such as within a church that has expressed its concerns about vaccinations (as in the recent outbreak in Texas).  When unvaccinated persons travel to an area that has not made as much progress towards eradicating disease, the likelihood of disease spreading is much higher.

This is true for other diseases as well.  The Texas Department of State Health Services has recently released a health alert regarding vaccination against pertussis (whooping cough) after more than 2,000 cases this year, including two deaths of infants too young to be vaccinated..  Says Dr. Lisa Cornelius, the Department’s infectious diseases medical officer, “This is extremely concerning.  If cases continue to be diagnosed at the current rate, we will see the most Texas cases since the 1950s.”

Although the potential risk of a vaccine may seem frightening, it is important to ensure that everyone in your family is fully vaccinated.  Not only will this provide the best protection for each of you, it will also provide protection to those members of your community who cannot be vaccinated, and limit the spread of these diseases.  Some communities are experiencing this the hard way. The Texas church involved in the outbreak has begun offering vaccination clinics for its members to attempt and stop the outbreak and protect against another one.

You can view the Outline and Cause Map discussing this issue by clicking “Download PDF” above.

Root Cause

Concern About a Resurgence of Black Lung Disease

By Kim Smiley 

Did you know that black lung disease has killed 70,000 coal miners since 1970?  Despite regulations designed to protect them, modern coal miners still face very real danger from coal dust.  Changes to the mining industry seem to be exacerbating this long standing issue.

Black lung disease, as coal workers’ pneumoconiosis is colloquially known, is caused by inhalation of coal dust, but there is more to the issue that needs to be understood.  The problem of miners suffering from black lung disease can be analyzed by building a Cause Map, a visual root cause analysis.  Cause Maps lay out the different causes that contribute to an issue visually to illustrate the cause-and-effect relationships.   (To view a high level Cause Map of this issue, click on “Download PDF” above.)

Coal dust is dangerous because it accumulates in the lungs and can cause long-term lung damage and breathing difficulties.  It is irreversible and there is no proven effective treatment.  Death can occur in severe cases.  The only option to fight this disease is prevention.

Black lung disease has a long history and concern about it first came to head in the 1960s.  A strike by 40,000 West Virginia coal miners pushed passage of the Federal Coal Mine Health and Safety Act of 1969.  This legislation limited coal dust exposure to 2 milligrams per cubic meter of air, which was significantly less than most miners were being exposed to at that time.  At first it seemed that the limits were effective in dramatically limiting black lung disease, but some are now worried about a resurgence of the disease.

Some speculate that changes in the mining industry are putting miners at greater risk for black lung disease.  The more dust that miners inhale, the greater the health risk and miners are both working longer hours and using equipment that potentially creates more dust.   The average workweek grew 11 hours since the 1970s which means miners are potentially exposed to dust for hundreds of more hours each year.  Technological advances have resulted in mining technology that is more powerful and can cut through coal faster, which can result in more dust.  The amount of coal produced per hour of work has nearly tripled since the 1970s.  These changes make it more challenging to prevent inhalation of dangerous levels of coal dust.  Increase in demand as well as the rising price of coal has driven these changes because it’s profitable to mine coal as quickly as possible.  Miners are also willing to work in the evolving conditions because mining provides a better living than other jobs available.

One of the most alarming pieces of evidence that cases of black lung may be increasing came from autopsies of the 29 miners killed in the blast at the Upper Big Branch mine in 2010.  The medical examiner was able to test tissue from 24 of the victims’ lungs and he found that 71% of those tested had black lung disease, a truly distressing percentage.  Some of the miners were relatively young and had a limited amount of time on the job.

There is no clear agreement on the best way to prevent black lung disease.  People are still trying to bound the problem and understand how significant the issue is.  But working to understand the problem is always the best first step to trying to solve it.

Root Cause Analysis

The Price of Beauty?

By Kim Smiley

In recent years, keratin-based hair products have become increasingly popular.  They smooth hair and many rave over their effective de-frizzing abilities.  These products are expensive, but are consumers paying an even higher price for beautiful hair?

Health concerns about the use of keratin-based hair products have been reported multiple times  over the past several years. The main issue is the formaldehyde contained in many of the products.  Formaldehyde can irritate the eyes and nose, cause skin rashes, and cause asthma-like breathing problems. Formaldehyde is also considered a carcinogen by many organizations.

These hair products contain formaldehyde because it makes the product more effective and longer lasting, but there may be a high health cost, especially to the stylists who perform the procedure.

This issue can be analyzed by building a visual root cause analysis called a Cause Map.  Click on “Download PDF” above to view a high level Cause Map for this issue.

During the root cause analysis, it became clear that one of the causes that contributed to this issue is that many people are unaware of the potential health risk.  This in turn is caused by mislabeling of the products and a lack of safety instructions on the packaging.  Testing by the Oregon OSHA found that many keratin-based hair products labeled as “formaldehyde free” in fact contained significant levels of formaldehyde.  Another cause to consider is that these hair products are considered cosmetics and cosmetics do not require pre-approval by the FDA prior to sale, resulting in minimal government oversight of the product.

OSHA and the FDA  are both investigating the products to determine their safety, but as of right now it is perfectly legal to sell and use keratin-based products containing formaldehyde in the US.  But if you’re interested in using these products, there are several facts you should know to help keep you as safe as possible.  When reading a package, it’s good to know that formaldehyde can be listed in multiple ways, including methylene glycol, formalin, methylene oxide, paraform, formic aldehyde, methanal, oxomethane, oxymethylene, or CAS Number 50-00-0.   It’s also safer to perform this procedure in a well-ventilated area or outside.  Additionally, wearing a mask will prevent inhaling the formaldehyde and some salons now provide them to consumers and stylists to use while the keratin hair products are applied.  You should also carefully wash your hands after handling any product that contains formaldehyde.