Root Cause Analysis Blog

Why do articles about medical errors have an erie similarity?

The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

http://www.hospitalcompare.hhs.gov

What hospital in your area has the best and worst record for a type of treatment that you need? See the link above, review the performance measures, and find out before you decide where to have treatment.

I’m not sure how a voluntary federal medical error reporting system will help. (How can voluntary data be seen as accurate?) But the system set up by law in the 2005 Patient Safety and Quality Act is starting to be implemented. See:

http://www.ama-assn.org/amednews/2008/05/05/gvsd0505.htm

Interesting article at:

http://www.woodtv.com/Global/story.asp?S=8230122&nav=menu44_2

An article in Advance for Nurses includes some interesting items:

Cost of a needle stick injury could = $1 million.

Fatigue, long hours, and shiftwork are a big cause of accidental needle sticks.

Best Safeguard … Go needleless.

The article is at:

http://nursing.advanceweb.com/Editorial/Search/AViewer.aspx?AN=NW_08apr14_n8p19.html&AD=04-14-2008

Needle Stick References:

http://nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles.aspx

A press release from Cigna:

As part of its ongoing focus on improving health care quality, CIGNA HealthCare is taking steps to stop reimbursing hospitals for so-called “never events” and avoidable hospital conditions, which are errors in patient care that can and should be prevented. CIGNA’s new policy is consistent with and based on the policy of the Centers for Medicare and Medicaid Services (CMS), and both policies will become effective on Oct. 1, 2008.

“CIGNA is committed to improving quality for our members throughout the health care system,” said Jeff Kang, MD, chief medical officer for CIGNA HealthCare. “Our policy on never events and avoidable hospital conditions is designed to put patient safety first and to encourage hospitals to improve quality every day, one patient at a time.”

“We commend CIGNA for its commitment to patient safety and quality improvement,” said Helen Darling, president of the National Business Group on Health. “Hospitals, health care professionals and health plans must all work together to ensure that ‘never events’ never happen, avoidable conditions are always avoided, and every patient receives quality treatment in a safe and caring environment.”

As defined in CIGNA’s policy, “never events” are surgical procedures that are performed on the wrong side, wrong site, wrong body part or wrong person. They earned that name because they should never happen in medical practice. For example, surgery erroneously performed on the right knee instead of the left knee, or the erroneous removal of a gall bladder instead of an appendix, are considered to be never events.

CIGNA will not reimburse for never events because they are not “medically necessary.” Surgery performed on the wrong side, wrong site, wrong body part or wrong person is not considered medically necessary to diagnose or treat an illness, injury or disease, and is therefore not reimbursable.

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The largest healthcare insurer in Ohio has announce that it will start implementing the Medicare rules and refuse to pay for treatment due to a medical error or a hospital acquired infection.

For more informations, see:

http://www.cleveland.com/medical/plaindealer/index.ssf?/base/news/1207211620124580.xml&coll=2

For ideas to stop medical errors, attend the Medical Error Reduction Track at the TapRooT® Summit in Las Vegas on June 25-27.

I previously wrote a blog entry about the wrong kidney being removed from a cancer patient.

Yesterday, I read an AP article with the following quotes:

“Twenty-four wrong-site surgeries were reported to the Minnesota Department of Health between October 2006 and October 2007. Two were at Methodist, but Carlson said they were relatively minor compared with last week’s error: a needle biopsy on the wrong lung, and a diagnostic exam of the wrong bronchial tube.”

“Kathleen Harder, a University of Minnesota researcher, said medical errors of this magnitude are rare but do happen.”

“Medical errors” certainly are NOT rare. The question is: “How rare are high consequence medical errors?”

The answer is: “No one knows.”

Why?

Because their is no national law that requires the reporting of high consequence medical errors to a central reporting agency.

Thus all statistics are a guess.

On top of that, to avoid liability errors may disguised as normal deaths. I read a sad story about a family being told that “every possible had been done” to save the life of their grandmother. They chose not to have an autopsy performed. Later, they found out that she had been administered large doses of blood thinner that may have contributed to, or caused, a fatal hemorrhage in her brain. The death would have been a natural death in the statistics. It would have gone unreported. Yet, the family now believes it was a covered up medical error that was detected by a nurse (a family member) reviewing the medical records.

I’m not a person that favors large government regulatory initiatives. And I’ve seen many government programs go astray. But unless the healthcare industry can come together to establish effective reporting and improvement programs, a large government lead regulatory initiative will surely be the eventual result.

If you are interested in efforts to reduce medical errors, you should participate in the TapRooT® Summit in Las Vegas on June 25-27. There is a Best Practice Track dedicated to medical error reduction. And you can network with experts inside the medical field and from a large variety of other industries. The cross industry networking may be the only hope for accelerated improvement in the healthcare industry. After all, as Sam Levenson quipped:

“You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.“

If you are in the medical industry leading an improvement effort, don’t miss this once a year chance to learn from others.

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Investing in advanced root cause analysis is a winning proposition.

For example, a Peoria nursing home had a chance to find the root causes of previous fall incidents and develop a plan to improve performance. Instead, a Peoria Journal-Star article quotes a Illinois Department of Public Health report as concluding that:

“This policy does not address investigation, tracking or monitoring of accident/incidents or how this data will be analyzed to identify trends and patterns to perform root-cause analysis in order to develop and implement corrective actions to address the falls occurring in the facility.”

The result? More falls and a $40,000 fine from the state.

That’s just one of many fines from the state that can be attributed to a failure to investigate problems and develop effective fixes to correct the problems’ root causes. Another was fined $22,500 and a third was fined $1,908.

Besides the fines, these nursing homes could have avoid injuries to their patients if they had addressed the root causes of quality of care issues.

Nursing homes are usually on a tight budget. but failing to invest in advanced root cause analysis and corrective actions is a fool’s bargain. Don’t be “Penny wise and Pound foolish.” Find out how TapRooT® Training can help your staff and get some signed up for one of our courses.

See:

http://www.californiahealthline.org/articles/2008/3/21/California-Fines-11-Hospitals-for-Lapses-in-Care-Delivery.aspx?topicID=47

See:

http://www.cbsnews.com/stories/2008/03/13/60minutes/main3936412.shtml

One kidney has cancer. The other is healthy. But the wrong one is removed. See story at:

http://wcco.com/local/kidney.surgery.methodist.2.679062.html

One of the Best Practice Tracks at the TapRooT® Summit is dedicated to reducing medical errors. See:

http://www.taproot.com/summit.php

Dramatic footage of a maintenance error…

It’s rare to see an audit or evaluation be this blunt. See:

http://www.smokymountainnews.com/issues/03_08/03_12_08/fr_hrmc_power.html

Could this audit be performed by an internal auditor?

Would it be possible to conduct an audit like this if the Hospital Administrator was still there? (He quit before the audit was conducted.)

Could the Board be more independent and should have they found the problems and forced the Administrator to Change (or fired him) before it came to the point of losing Medicare certification?

What do you think?

See:

http://health-care-jobs.advanceweb.com/search/Fullresults.aspx?A=6&SOI=0&IL=949896

This short newspaper article starts to provide the information needed to draw a SnapCharT® that would have many Causal Factors. Read the story and then try drawing a SnapCharT®.

Link to story:

http://www.news.com.au/heraldsun/story/0,21985,23323474-29277,00.html

For those that aren’t aware, I am the Summit Chair and with the help of the TapRooT® Advisory Board, the Track Chairs, the staff at System Improvement, and previous year Summit participants (that a lot of help!), I plan the TapRooT® Summit.

I also hand pick the courses that are offered prior to the Summit - this year on June 23-24. I pick these courses based on the experience I have with performance improvement programs around the world. My goal is to put together a world-class selection of courses that will help people solve their toughest problems.

Each year I bring back some old favorites and some brand new courses.

The old favorites are based on previous attendance and feedback.

The new courses are based on requests from participants and problems that I observe in my extensive travels.

This year there are three new courses:

1. Hazard Recognition Best Practices

2. Engineering Equipment Reliability Techniques

3. TapRooT® and FMEA for Healthcare Root Cause Analysis

There are also, eight returning veterans:

1. Advanced Trending Techniques (10th year)

2. Innovation & Creative Solutions (2nd year)

3. Stopping Human Error (5th year)

4. Risk Management Best Practices (5th year)

5. Interviewing and Evidence Collection (3rd year)

6. Getting the Most from Your TapRooT® Software (2nd year)

7. 2-Day Equifactor® Equipment Troubleshooting & Root Cause Analysis Course (8th year)

8. 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course (13th year)

That makes 11 courses with a wide variety of topics to choose from. Where can you find out more information? See:

http://www.taproot.com/pre-summit_courses.html

And here are a couple of videos where previous course attendees share their experience…

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A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.

Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.

What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).

Bill Sirois, VP and COO of Circadian Technologies, will be presenting three sessions on fatigue and the investigation of fatigue as the cause of accidents. The sessions are:

Human Error Reduction & Behavior Change Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Investigation & Root Cause Analysis Best Practices Track:

• FACTS - Computerized Analysis of Fatigue as a Cause of an Incident

Medical Error Reduction Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

For additional Summit information, see:

http://www.taproot.com/summit.php

The Food and Drug Administration (FDA) found that a Chinese plant is at the center of a controversy over the safety of Baxter’s blood thinning drug heparin. Changzhou SPL has problems with impurities, the quality and use of its equipment, and overall quality control. These problems were found in a preliminary inspection by the FDA.

You may remember that in a previous blog entry, the FDA had declined to inspect the plant because of a name mix-up in the FDA’s manufacturer database.

For more information, see:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/28/AR2008022803046.html?hpid=moreheadlines

I wrote about this amazingly stupid government decision to stop research into imporving patient care by using a checklist, but I came across this link to the New Yorker magazine article, so I thought I should include it here:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

If you agree that this is outrageous, write the White House, your Congressman, and your Senator.

Use these links:

Contact the President and Vice-President about this at:

http://www.whitehouse.gov/contact/

Write your Congressman about this by using the following link:

https://forms.house.gov/wyr/welcome.shtml

Write your Senator at this link:

http://www.senate.gov/general/contact_information/senators_cfm.cfm

The healthcare industry is searching for ways to improve healthcare quality, drive down healthcare costs, and stop sentinel events. After a decade of searching for answers, some healthcare professionals are frustrated. Progress just doesn’t seem to come fast enough.

What can healthcare professionals (safety, quality, & risk management professionals, doctors, nurses, and administrators) do to learn proven, effective ways to improve performance and stop sentinel events while reducing healthcare costs? Attend the TapRooT® Summit and learn from other healthcare professionals and from experts in other high reliability industries.

First, the Summit has a track designed just for those looking to improve performance in the healthcare industry. The Medical Error Reduction Track includes the following sessions and speakers:

Morbidity & Mortality Reviews (Hot Case Rounds) - DR. Johnny Griggs, MD, plus David Davis, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc. & Tommy Garnett, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc.

Measuring Performance
1) The Latest Research on Performance Measures - Dr. Joel Haight, Penn State University
2) Applying Performance Measures in Industry & Healthcare - Dr. Joel Haight, Penn State University

The Human Design Spec - Working in a 24/7 Medical Environment - Bill Sirois, VP, Circadian Technologies

Improving Patent Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, Patient Safety Consultant, The Kicklighter Group

TapRooT® User Success Stories from Healthcare & Industry - Linda Unger & Barbara Phillips (facilitators)
MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

Process for Running a Healthcare Root Cause Analysis - Tommy Garnett, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc. & David Davis, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc.

Innovative & Creative Solutions - Michele Lindsay, Principal Consultant, P2, Canada

Planning Your Improvements

In addition to these sessions focussed on healthcare performance improvement, there are general sessions for cross industry lessons learned and inspiration.

These General Sessions include these talks:

Lt. Col. Ralph Hayles (retired), Gulf War Veteran, Lessons Learned from Friendly Fire

Nikki Stone, Olympic Aerial Skiing Gold Medal Winner, Overcoming Setbacks to Achieve Olympic Success

Carolyn Griffiths, UK Rail Accident Investigation Branch Chief Inspector, Lessons from Setting Up an Independent Accident Investigation Organization

Ed Frederick, Exelon Nuclear (Board Operator at TMI during the accident), The Accident at Three Mile Island - An Insider’s Perspective

Marcia Wieder, Doctor of Dreams, You Can Make Improvement Happen

But that’s not all. There are exceptional opportunities to network with industry leaders from the healthcare industry and from other high reliability industries (aviation, nuclear power, military, refining, and many others).

So don’t hesitate to sign up for this guaranteed, amazing Summit of performance improvement leaders.

See:

http://www.taproot.com/summit.php

for registration information.

Dr. Mark Chassin, new President of the Joint Commission, has an ambitious goal. His goal is to make healthcare delivery meet the same high reliability standards as the best high-reliability industries. Who are these “best” high-reliability industries? Speaking during a January 31, 2008, teleconference, he identified the aviation and nuclear power industries as today’s best high-reliability organizations.
Why is this important?

If you are at a hospital and you would like to learn best practices to improve patient safety AND network with people from the aviation and nuclear power industries (as well as industry leaders oil industry, mining, and manufacturing), where should you go?

Answer: The TapRooT® Summit on June 25-27 in Las Vegas, NV.

Plus, if you aren’t already a TapRooT® User, you should attend the TapRooT® and FMEA for Healthcare Root Cause Analysis Course on June 23-24, also in Las Vegas.

This is the best place to learn high reliability best practices that cross industries and can revolutionize patient care.

For more information, see:

http://www.taproot.com/summit.php

And while you are there, watch the videos from previous Summit attendees to see what everyone is talking about.

And check back at this blog tomorrow for a complete run-down on the Medical Error Reduction Best Practices Track at the TapRooT® Summit.

I was reading root cause related articles when I came across this one by a doctor:

http://www.medpagetoday.com/Blogs/8395

A very interesting (and perhaps depressing) perspective on medical root cause analysis.

What do you think about his views? Leave a comment here.

Two different plants. Two similar names. Oops! Wrong plant!

If you’ve been following the FDA investigation of allergic reactions to Baxter’s heparin blood thinner, you know that a Chinese manufacturer is supplying a key ingredient. The supplier that produces the ingredient was not previously inspected by the FDA because the FDA went to the wrong plant. It seems there are two plants with similar names in the agency’s database.

Joseph Famulare, Deputy Director of the Compliance Department at the FDA’s Center for Drug Evaluation and Research said that the wrong factory had a history of positive inspections and wasn’t re-inspected. This month, they discovered their error. Famulare says that as far as the FDA knows, this is an isolated error. FDA inspectors will travel to China this week to check the right plant.

The FDA has notified Doctors to stop using Baxter’s heparin because of 350 reports of adverse reactions (including deaths) this year.

For more information see the Associated Press story at:

http://www.chron.com/disp/story.mpl/world/5550954.html

An 86-year-old woman (under anesthesia and not conscious) was dropped from a surgery table when a safety belt was released in preparation for transferring her to a mobile hospital bed. She died as a result of the head injury.

The family is suing. The article about the death said:

“The investigative report said the hospital did its own root cause analysis and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the ‘removal of the . . . safety belt from the patient was not verbally communicated.’”

“The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.”

I know this isn’t a complete Sentinel Event Report, but what do you think of “communication” and a policy of “putting their hands on the patient and having people on both sides of the bed before removing the safety belt” as the Safeguards to prevent future accidents? Are these Safeguards strong enough? Will they be effective?

Leave a comment and let me know what you think…

ADDITION:

Here’s what the table looks like (I think):

Here’s another example:

Or another:

An interesting story from American Samoa points out that hospitals can’t release information on a healthcare root cause analysis unless the patient consents.

See:

http://www.pacificmagazine.net/news/2008/01/25/lbj-medical-center-wont-release-information-on-governor

for the whole story.

A story in The Mail on Sunday, a UK paper said:

Elizabeth Ward, of the British Kidney Patients Association, said: “I’m quite sure it’s the first time this has happened in this country. It’s hard to understand how this could have happened.”
What was she talking about? A kidney transplant patient was forced to have the new organ removed after just a few hours – when it was discovered that the patient’s blood type had been incorrectly recorded on a computer database.

The incident, which was only revealed in response to a Freedom of Information request, comes just days after Gordon Brown called for a system in which individuals are presumed to consent to the use of their organs for transplant unless they specifically stipulate otherwise.

The error took place three years ago and would have remained secret had The Mail on Sunday not seen a confidential report into the “profound error”.

The internal investigation did not name the hospital involved. The report concluded that the initial data entry mistake was “human error” but said “there was no means of identifying” who did it, or where the incorrect information had been entered.

Although the mistake was made by Hospital Trust staff, the report blamed UK Transplant for failing to set up a standard nationwide system for entering patient details. It said: “During this investigation it became apparent that any number of professionals could have entered the blood results on to the computer.

“UK Transplant do not have a uniform system in place. [They] have not been prescriptive in dictating practice, and have allowed local Trusts the freedom to adopt whatever systems they deem fit.”

But a spokeswoman for UK Transplant said the report was “misleading” as the organization had no responsibility for the way Trusts entered information. “We need to be clear that the mistake here was not with UK Transplant,” she said.

“Information that Trusts provide is what goes into the national database. In this case, we have correctly recorded incorrect data. Our system has been in place for several years and can be viewed by Trusts at any time to check the data we’re holding.”

Once again, BLAME (rather than a fix for the problem) seems to be a major issue.

A source at UK Transplant said the mistake was “extremely rare” as fewer than five of the 20,000 organ transplants in the past seven years were made in error.

Hmmm … 5 in the past seven years? That sounds like more than “This has never happened before.” And if the reports aren’t made public, how can this error rate be verified?

For the complete article, see:

http://www.mailonsunday.co.uk/pages/live/articles/news/news.html?in_article_id=509289&in_page_id=1770

Sometimes you read stories and you just can’t believe what you are reading.

For example, a New York Times story explained that a government office - the Office for Human Research Protection - shut down a John Hopkins University research project.

The project was using checklist to reduce post-operative infections. Using 5-step checklist had cut the rate of bloodstream infections acquired in the I.C.U by two-thirds. Over 18 months, the program saved 1,500 lives and $200 million dollars.

So why did the government shut it down? The study was breaking the rules. What rules?The NY Times article said that:

“…by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations.”

Here is the logic for the finding reported by the NY Times:

“A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore, it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.”

By this tortured logic, I’m surprised that any study or improvement efforts are allowed in the medical field. No wonder improvement in the medical industry progresses so slowly.

“Canada ranks 23rd out of 30 countries surveyed in “consumer friendliness” of its health-care system” cites a report by European and Canadian researchers in the Canadian Press. Having more in common with publicly financed and governed European health-systems, the “think tank” researchers wanted to compare Canada with like populations in this first annual “consumer index”. Not including publicly-commercially financed countries such as the United States would provide a better base-line of performance for Canada.

What will the affect of this study be? Canada performed well in survival rates of heart attack, cancer, and other medical procedures, but failed in areas such as treatment waiting times, range of services available, and access to new diagnosis tools and new medicine. First question to ask is whether there were countries that performed well in the latter categories but failed in survival rates? As a medical consumer, what is more important to you, survival rate or “friendliness”? As a medical business, what is important, survival rates or “friendliness indexes” that would bring new customers to your business or longer term survival rates? If business operation policy is changed to perform well in this survey, this will also affect how you perform future sentinel investigations.

As a medical health-system provider, should you chance changing your policy and procedures based on this survey? When business risk assessments and hazard risk assessments diverge this is bad practice. This practice tends to split quality, safety, and operation personnel reducing a one-company mission. How can you prevent this company split? Ensure sentinel investigations and corrective actions are based on accurate human performance and equipment root cause analyses? If you see this bad practice occurring in your medical health service, you may find TapRooT® an effective solution. Contact us from this site to learn what medical health providers have taken on this challenge with TapRooT®.

The following is an excerpt from Appendix B in the upcoming TapRooT® - Changing the Way the World Solves Problems - book. The material is copyrighted and is used here with permission of System Improvements.

Comparing TapRooT® to 


Other Root Cause Tools

Price is what you pay. Value is what you get.…

Risk comes from not knowing what you’re doing.

Warren Buffett 

Choosing the tools you will use to improve performance is one of the most important choices that a business can make. The tools you choose and the systems you set-up, along with the people who use them, will determine your company’s performance in the future. By Warren Buffett’s theory, you need to know what you are doing or you will be taking unnecessary risk.

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The third strike for wrong site operation during brain surgery, could it have been prevented? What changes for those who did not die were made in these patients’ personalities and thought processes? “While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital,” stated the director of health for this facility. How often we as a company struggle to fix the system without involving all that touch it. If you would like to change the system look through the TapRooTç success stories, see how it is possible to operate with the right and left side of the brain using our human factors driven process.

One of the elements of the revised standard that I thought would interest readers of this blog is  LD.4.260. It states that:

The organization implements an integrated resident safety program throughout the organization.

LD.4.260 includes 13 specific elements:

1. There is an organization-wide, integrated resident safety program.

2. One or more qualified individuals or an interdisciplinary group manages the organization-wide safety program.

3. The scope of the program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events, which have serious adverse outcomes.

4. All departments, programs, and services within the organization participate in the safety program.

5. The organization creates procedures for responding to system or process failures, such as continuing  to provide care, treatment, and services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.

6. The organization: Defines responses to various types of potential adverse events. 

7. The organization: Conducts proactive risk assessments.

8. The organization: Makes support systems6 available for staff members who have been involved in a sentinel event.

9. The organization: Analyzes and uses information about a system or process failure to improve safety.

10. The organization: Provides systems for the internal and external reporting of a system or process failure.

11. The organization: Provides governance at least once a year, with written reports on all system or process failures, on the number and type of sentinel events, on whether the residents and the families were informed of the adverse events, and on all actions taken to improve safety, both proactively and in response to actual occurrences.

12.  The organization: Disseminates lessons learned from root cause analyses to staff who provide services or are affected by the situation.

13. The organization: Encourages external reporting of significant adverse events, including voluntary reporting programs in addition to mandatory programs.
To review the revised program see:

http://www.jointcommission.org/NR/rdonlyres/CD9A619C-C364-4543-A840-50E9AD914E17/0/09_ld_ltc2_prepubstds.pdf

A miner received a head injury during a rock slide at a mine. Because of hospital “downgrades”, emergency treatment was delayed. The article and the ABC web site states:

“The groundswell of anger is becoming quite near to a boiling point I think. People have just had enough.”

See:
http://hscweb3.hsc.usf.edu/health/now/?p=272

What is the “Never Event” Pledge?

If a hospital agrees to the Never Event Pledge, the hospital pledges to:

• Apologize to the patient and/or family affected by the never event;
• Report the event to at least one of the following agencies: the Joint Commission, a state
reporting program for medical errors, a Patient Safety Organization;
• Perform a root cause analysis, consistent with instructions from the chosen reporting
agency; and,
• Waive all costs directly related to the serious reportable adverse event.

Since this seems very reasonable, it seems surprising that more hospitals have not agreed to the pledge.

For the complete press release from the Leapfrog Group about this survey, click on the link below.

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The Sydney Morning Herald reported that the head of surgery at Mount Druit Hospital complained about a recent root cause analysis and implied that staffing changes and shortages are a danger to emergency patients. For more information see:

http://www.smh.com.au/news/national/surgeons-fear-hospital-unsafe/2007/09/21/1189881777216.html

See Henry the Hand for more info.

Risk Manager will:

• Collect, review and monitor reported incidents
• Conduct investigations and facilitate root cause analysis
• Investigate potential and actual claims
• Recommend preventive actions and claims management strategies.
• Collaborate with Patient Representatives and other staff to resolve patient complaints
• Assist in preparation of responses to interrogatories and production requests.
• Develop/conduct orientation and other educational programs
• Serve as a resource to staff in areas related to clinical quality and risk management

For more information see:

http://www.job.com/my.job/search/page=jobview/key=13194614/pt=2/r=98/ns=1/f=60/rpp=20/us=467/jsOn=1/

See:

http://news.gov.hk/en/category/healthandcommunity/070817/html/070817en05004.htm

For more information see:

http://www.chron.com/disp/story.mpl/nation/5066044.html

Safety Coordinator
Date Submitted: 2007-08-16
Hiring Organization: Mayo Clinic
Location: Rochester, MN
(more…)

See this link:

http://www.psqh.com/julaug07/tortreform.html

When a patient in injured or killed by a sentinel events, the doctor may also suffer. To download a copy of an interesting article, see:

http://www.bmj.com/cgi/reprint/320/7237/726

When I saw this article I thought it was new. Then I looked at the date at the bottom of the page. The article was from 2000! That made me think …

What has actually changed in the past 7 years in the efforts to achieve greater patient safety and quality of care? Have most of our solutions just been “band-aids”? Have we really made significant change in the reporting, root cause analysis, and correction of the causes of medical errors across the industry?

What do you think? Click on the title word “comment” below to leave your ideas…

Another state is considering their own law to improve patient safety and reduce preventable sentinel events. The Missouri Senate is considering a bill that requires incident reporting within 24 hours of the incident and root cause analysis within 20 days.

The bill defines root cause analysis as:

(6) “Root cause analysis”, a structured process for identifying
79 basic or causal factors that underlie variation in performance,
80 including but not limited to the occurrence or possible occurrence of
81 a reportable incident. A root cause analysis focuses primarily on
82 systems and process rather than individual performance and
83 progresses from special causes in clinical processes to common causes
84 in organizational processes and identifies potential improvements in
SB 578 7
85 processes or systems that would tend to decrease the likelihood of such
86 events in the future, or determines after analysis that no such
87 improvement opportunities exist.

To read the bill, see:

http://www.senate.mo.gov/07info/pdf-bill/intro/SB578.pdf

For the legislative status of the bill, see:

http://www.senate.mo.gov/07info/BTS_Web/Bill.aspx?SessionType=R&BillID=45607

As of July 1, 2007, California law SB 1301 requires hospitals to report adverse events within five days to the California Department of Health Services (DHS). The law categorizes 27 types of adverse events that require reporting. What if the event is an ongoing, urgent or emergency threat to the welfare, health or safety of patients, personnel or visitors? Then the hospital must report the event within 24 hours.

For more information, see:

http://pub.ucsf.edu/today/cache/news/200707172.html

To read the article, click on the headline below: