Electrocution
Cause Mapping Example:
This is an example of how the Cause Mapping process can be applied to a specific incident. In this case a patient electrocution is captured as an example of the Cause Mapping method. The three steps 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 of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? The problem we are looking at here is that a patient was electrocuted. We don't know when it occurred. It happened at a medical facility, during heart monitoring. Additionally, we add that a 'difference' in this case was that the heart monitor was plugged into an IV pump.
The magnitude of this incident is defined by the impact to the goals. We capture the impacts to the goals on the outline as well. Here, a patient died, which is an impact to the patient safety goal. The staff was devastated by the death, which is negatively affects the employee impact goal. Electrocution is a "never event", so it impacts the compliance goal. The completed outline is shown below.
Step 2. Identify the Causes (The Analysis)
The analysis step is where 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. For the electrocution, the patient safety goal was impacted because of the patient death, the employee impact goal was impacted because of the devastation of the staff, and the compliance goal was impacted because electrocution is a "never event".
The analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. The next question is “Why was the patient killed?” The patient was killed because she was electrocuted.
The patient was electrocuted because she was hooked up to a heart monitor, and electricity flowed through the heart monitor. Note that both of these causes are required. Patients are not normally electrocuted by being hooked up to a heart monitor.
Electricity flowed through the heart monitor because the IV pump was plugged into the wall outlet, and the heart monitor lines were plugged into the IV pump.
The heart monitor lines were plugged into the IV pump because they were able to be plugged in (that is to say, it was physically possible to do so), the staff was attempting to reconnect the heart monitor, and there was confusion between the monitor and the IV pump.
Based on the information provided, we don't know why the monitor and IV pump were confused. For now, we put the Cause as unknown (?). This question mark indicates an area that requires more investigation to truly determine the causes of the problem.
The staff was attempting to reconnect the heart monitor because the monitor and pump had been disconnected in order to administer treatment.
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.
Step 3. Select the Best Solutions (Reduce the Risk)
Once we have put in all the causes that are known so far, we can begin looking for solutions. Any cause can have a solution, but not all causes will. Solutions are placed on the Cause Map, above the cause they control. The two solutions implemented as a result of this incident are 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.
Return to Healthcare Home Page