Infant Heparin Incidents [ October 16th, 2008 ] Posted in » Root Cause Analysis - Incident Investigation

Root Cause Analysis :: Infant Heparin IncidentsIn 2006 in Indianapolis, 6 newborns were given adult doses of the blood thinner heparin.  Adult doses are 1000x more concentrated than infant doses.  Three of the babies died.  In 2007, in Los Angeles, the same thing happened to three babies.  Luckily none of those babies died.  (The heparin overdoses that occurred in Texas in 2008 were caused by a different type of error.)

A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

Overdoses of this sort impact the patient safety goal because they can result in fatalities and injury to newborns. 

In order for this to have occurred, there were 5 opportunities for double-checking the dosage that were missed. 

The wrong dosage was missed as 1) the bottle was removed from the pharmacy, 2) the bottle was placed in the cabinet, 3) the bottle remained in the cabinet, 4) the bottle was taken from the cabinet, and 5) the drug was adminstered to the babies.  Some of the reasons that it was missed: there was no effective double check by another staff member, there was no check by a computer and of course due to human error, which was aided by the issue that the adult dosage bottle and the infant dosage bottle looked practically identical (this has since been remedied).

Many solutions to this type of error (such as requiring double checks by staff members and using a computerized prescription dispensation system) are already being implemented at hospitals across the nation.

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Commuter Rail/Freight Train Collision

Root Cause Analysis Train CollisionOn the afternoon of September 12, 2008, a Metrolink commuter train collided head-on with a Union Pacific freight train.  This tragic accident resulted in the deaths of 25, and injured 135, one of the worst train collisions in the country.  The National Transportation Safety Board (NTSB) is investigating the collision, but from primary information we can make a basic cause map.  A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

We’ll examine the impacts to the goals from the point of view of Metrolink, who operates the commuter rail.  There was an impact to the safety goal because 25 (20 passengers, 5 crew) were killed, and 135 were injured.  The customer service and production goals were both impacted because rail service has been suspended.  Additionally, there was severe damage to both trains, though the total cost is not yet known.

The suspension of service is due to the damage to the trains.  The deaths, injuries and damage to the trains were caused by the impact force.  The impact force is a result of the head-on collision of the two trains, which were both estimated to be traveling at 40 m.p.h.  (Whether or not that is a typical or accepted speed is not yet clear.)  The head-on collision occurred because the two trains were sharing the same tracks.  There is only a single track in this area because of a narrow tunnel, and the commuter train did not pull over onto siding (as occurs nearly almost every day so the freight train can pass).  The train did not pull over because the engineer failed to stop.  Whether that is because he didn’t follow protocol, didn’t notice the signal because of glare, fatigue, or other distractions, or if the signal malfunctioned is not yet known.  (A preliminary investigation by Metrolink indicated that the signal was functioning properly.)

As the NTSB completes its investigation, we will be able to add more detail to this map and remove potential causes that have been shown by investigation to be inappropriate.  As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.

September 22nd, 2008 | Leave a Comment

Heart-Lung Transplant Blood Type Mismatch

On February 22nd, 2003, a patient at Duke University Medical Center died after receiving her second heart-lung transplant.  The first transplant she received was rejected by her body due to a blood type incompatibility (she was Type O, the organs were Type A).  The loss of her life was tragic enough, but it was compounded by the fact that the two rare heart-lung block donations she received could have saved the lives of others as well.

Thinkreliability :: Root Cause Analysis :: ExampleWe can perform a thorough root cause analysis built as a Cause Map that can capture all of the causes in a simple, intuitive format that fits on one page.  Download this one-page document to see the midlevel Cause Map and write-up.  The death of a patient was an impact to the hospital’s patient safety goal.  The loss of the organs was an impact to the patient services goal. 

The mismatched blood type organs were transplanted because the procuring surgeon (sent to pick up the organs) was not told of the blood type, so he could not perform an effective blood matching.  Donor services offered organs with the incorrect blood type because they didn’t ask what that was, possibly because the surgeon had specifically asked for the organs for this patient, and they assumed that a surgeon wouldn’t ask unless the blood type was correct.  The surgeon didn’t verify the blood type of the organs because he assumed that donor services wouldn’t offer an organ of the wrong blood type (which is normally the case, per their regulations).  The mismatch was discovered in the laboratory, but not until too late in the procedure, because the surgery must begin while the organs are en-route, due to limited viability of the organs.

This tragic incident demonstrates the problem in making assumptions, and it shows us some areas where transplant safety can be improved.  Although this was a very rare case, both hospitals and the donor services are making improvements to their systems to ensure this never happens again.

September 7th, 2008 | Leave a Comment

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