Patient Burns
Cause Mapping Example:
Patient trauma due to burns has been added to the list of "never events" and hospital-acquired conditions no longer eligible for reimbursement from Medicare/Medicaid. We'll look at some potential causes of patient burns as an example of how the Cause Mapping process can be applied to a specific incident.
The three steps in the Cause Mapping process are 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.
Step 1. Define the Problem
The first step in the Cause Mapping process is to provide information about the issue and frame the problem with respect to the organization's goals. Because we are looking at the general, broad problem of patient burns, we don't have any specifics with respect to the when and where. But even with a generalized issue, we can still examine the impacts to an organization's goals. Here we'll look at burns affecting the hospital system in general. Patient burns can cause patient death or serious injury. This is an impact to the patient safety goal. Since patient burns are "never events", these would impact the compliance and organizational goal. Lastly, because hospital costs associated with burns may not be reimbursed, this is an impact to the materials and labor goal. The outline for patient burns is shown below.
Step 2. Identify the Causes (The Analysis)
In the analysis step, the incident is broken down into causes which are captured on the Cause Map. The Cause Map starts by writing down the goals that were affected as defined in the problem outline. These make the first cause-and-effect relationships in the analysis.
Beginning with one goal (we'll start with the patient safety goal), ask "why" questions and fill in causes to the right. For example, the potential for patient death or serious injury is caused by a burn.
We can add in the other impacted goals as shown.
We continue to ask "why" questions and move to the right. The two causes of patient burns that we'll look at (there are nearly infinite possibilities) are burns caused by exposure to hot equipment, which could be caused by an electrosurgical device being placed on a patient, or surgical fires. We'll look at surgical fires in more detail.
Surgical fires, like all fires, require three causes: an oxidizer, fuel and an ignition source (heat). The Cause Map for this is shown below.
The oxidizer could be ambient air, nitrous oxide, or an oxygen-enriched atmosphere.
Some typical fuel sources (based on case studies from literature) are common OR material, such as gowns, drapes, and dressings; volatile prepping solutions and ointments; patient's hair; and body gases. This list is by no means definitive. More causes can be added with input from your team.
Two common ignition sources are lasers and electrosurgical devices. Again, your team may have some additional causes to add to this list.
Even more detail can be added to this Cause Map as the analysis continues. 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. Evidence and supporting information can be added to the cause boxes (shown in pink).
Step 3. Select the Best Solutions (Reduce the Risk)
Once the Cause Map is built to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. Solutions are shown on the Cause Map, directly above the causes they control, as shown below.
An issue should be worked to a sufficient level of detail to prevent the incident, meaning to reduce the risk of the incident occurring to an acceptable level. This is why solutions and work processes at a coffee shop are not as thorough or detailed as an airline or nuclear power facility. The risk or impact to the goals dictates how effective the solutions should be. Lower risk incidents will have relatively lower detail investigations while significantly high risk to an organization’s goals requires a much more through analysis. The entire Cause Map we have built so far, including solutions, is shown below. It is also shown on the downloadable PDF. (To download, click "Download PDF" above.)
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.
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