October 24, 2008 | Mark Paradies

Child Has Wrong Kidney Removed – Press Releases, News, Investigation – But They Didn’t Find Root Causes!

I started reading about this sentinel event in the Irish Times:

http://www.irishtimes.com/newspaper/breaking/2008/1023/breaking47.htm

Then I visited the press release at the hospital’s web site:

http://www.olchc.ie/MediaRoom/

Next, the independent sentinel event report:

http://www.olchc.ie/MediaRoom/FileUpload,2132,en.pdf

And the policy for Correct Site Surgery:

http://www.olchc.ie/MediaRoom/FileUpload,2133,en.pdf

All very interesting.

Here are the root causes as listed in the report:

1. Delays in filing hard copy x-ray reports in the medical records, and lack of reference to an electronic
copy.
2. Patients are regularly admitted outside normal working hours.
3. Radiology is not normally sent to the ward or to theatre.
4. Formal consent is generally taken by surgeons who are not competent to perform the procedure.
5. The person taking consent for a procedure will not normally review imaging.
6. SpR hours and workload, and concomitant lack of planning for cross-cover.
7. The hospital has no site marking policy, or common practice.
8. The operation and planning of the parallel theatre list.
I think the report’s “root causes” were actually Causal Factors in TapRooT® terminology and that the independent report didn’t get to root causes or generic causes. I’m not sure if these are all the Causal Factors because I didn’t see enough information in the report to create a good SnapCharT®.

Instead of finding root causes, the independent investigation team jumped from Causal Factors to corrective action recommendations. These recommendations are based on the investigation team’s knowledge and biases. They may work … They may not.

Because the team didn’t completed a real, advanced root cause analysis and because the odds of a reoccurrence are so low, we may never be able to tell if the team’s recommendations will solve all the problems that caused this tragic sentinel event.

One last comment … Perhaps the most amazing fact is that they think they found root causes when they really did not. And these are the experts brought in for that purpose…

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