For morning snack on September 11, 2014, a substitute teacher’s aide was getting ready to pour water for snack on her first day on the job. Unfortunately, what she poured from a reused plastic milk container was actually a beach solution used for cleaning. The mistake was realized quickly, but not before 28 children and 2 adults ingested some of the bleach. Luckily the concentration was low enough that there were no injuries, although all who ingested the solution were seen at a local hospital.
The substitute teacher’s aide was fired and the school reopened the next day, though the New Jersey Department of Children and Families will be investigating. Clearly serving cleaning solution to children under your care is undesirable. However, firing the person most directly involved without fixing any of the issues that contributed to the mistake may leave an unacceptable risk for the issue to happen again. Although this appeared to be the first time anything like this happened on such a scale in a day care facility, the misuse of cleaning fluid due to confusing containers has happened before. Just this July a woman was given an epidural of cleaning fluid after containers were accidentally switched. (See our blog to learn more.)
Identifying the impacted goals and all the causes that led to those impacted goals allows for more solutions than just firing the person found to be most immediately responsible. The use of a Cause Map, a visual form of root cause analysis, diagrams all the cause-and-effect relationships in order to develop as many solutions as possible so the most effective among them can be implemented.
First the impacts to the goals are identified. The safety goal is impacted because of the potential for injury to the 28 children and 2 adults who drank the bleach solution. The bleach solution was stored in a food container, which can be considered an impact to the environmental goal. The customer service goal is impacted because the children and adults were served bleach solution. The day care worker being fired, and the ongoing investigation by the licensing agency, can both be considered impacts to the regulatory goal. Additionally, the treatment of all 30 who ingested the solution impacts the labor goal.
Beginning with one impacted goal, we ask “why” questions to determine cause-and-effect relationships. In this case, the safety goal impact of potential injury is due to the children and teachers drinking the bleach solution they were served. The bleach solution was served by the fired employee who was apparently unaware that the milk jug actually stored bleach solution. The executive director indicated that the jug was labeled, so this is apparently not an uncommon practice at the site. The question this raises is, why was an old milk jug used to store cleaning solution?
The American Association of Poison Control Centers (AAPCC) says: “DO NOT use food containers such as cups or bottles to store household and chemical products” and “Store food and household chemical products in separate areas. Mistaking one for the other could cause a serious poisoning.” Although the reused container was apparently labeled (though not clearly enough to avoid the mistake), it should never have been reused in the first place. As indicated by the AAPCC, reusing containers between food and cleaning supplies is just too big of a risk. It’s also worth noting that reusing a bottle that contained household chemicals for a different household chemical is another no-no: “Never mix household chemical products together. Mixing chemicals could cause a poisonous gas.” Don’t run the risk at your workplace or home. Don’t reuse food containers for cleaning products or mix cleaning products. Fortunately the children at this day care center got off without lasting damage in this case.