Patient Falls
Cause Mapping Example:
Unfortunately, falls are extremely common at home, at the workplace and pretty much everywhere. Falls are also common at healthcare facilities. However, the costs for treatment of falls that occur at healthcare facilities will no longer be reimbursed by Medicare & Medicaid. Healthcare facilities are working on reducing this problem. The best way to find solutions for a problem is to perform a root cause analysis.
Because there are so many different ways that falls COULD happen, we will look at a specific case in which a fall DID happen. We will analyze this specific incident using the Cause Mapping process, which is a visual root cause analysis. The resulting investigation, shown below and in the attached PDF, outlines the problem and solution in a clear, easy-to-understand way that everyone can benefit from. 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? One person may say that the problem was a patient injury. Another person might say that the problem was that the patient fell. We can write down both of these "problems” on the first line. In the Cause Mapping methodology the facilitator anticipates that the group may disagree so all three responses are written down. There is no need to spend time debating the problem. The magnitude of this incident is defined by the impact to the goals.
The second question is the "When?" which is the date and time of the incident. When captures the timing of the issue and also has a line for what was different or unusual in this occurrence. The question of what was different is fundamental in any investigation. On the patient fall issue we capture the date and time of the incident, and note an important difference: the patient was disoriented and confused.
In an investigation there can be several pieces of information that need to be captured when specifying the location. At a minimum the physical/geographic location and the process should be captured. The physical location is where geographically the incident happened. Here, it occurred in the imaging center, during radiography.
The next section is the impact to the overall goals. An important goal of healthcare facilities is to ensure patient safety. Here, the patient had a serious injury (he was blinded in one eye). We'll also consider this an impact to the patient services goal. Additionally, the compliance goal was impacted because this is a "never event". The organizational goal was impacted due to the maximum allowed fine, of $25,000.one of the overall goals is to have zero injuries. Other goals may have been impacted, but the patient safety goal is the most important.
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 example, the patient safety goal and patient services goal were impacted because of the serious injury to the patient. These are the first two cause-and-effect relationships in the analysis.
The analysis can continue by asking Why questions and moving to the right of either of the cause-and-effect relationships above. So, next we ask, "Why did the serious injury occur?" The patient was blinded in one eye due to damage to that eye. The damage was caused by a fall from the x-ray table.
Why did the patient fall from the x-ray table? The patient was not strapped to the table, and it is believed that he attempted to get off. Even though we don't know this for sure, we add it as a cause, with a question mark. Not being strapped to the table is not sufficient to cause the fall from the x-ray table; plenty of patients are not strapped to the table and they do not fall. There has to be an additional cause.
We look at each of these two causes in turn. First, why wasn't the patient strapped to the table? The patient was not strapped to the table because hospital policy wasn't followed. The patient was identified as a high falling risk by the staff, as required, which meant it was required that he be strapped to the table. (We add that information as evidence.) We don't know why the policy wasn't followed even though it was required. So, we'll leave that cause a question mark. But regardless of the cause, it may have been caused by inadequate training, or inadequate supervision. Since these are just possibilities, we leave them with question marks.
Now we look at the other cause of falling: the possibility that the patient attempted to get off. Although we don't know that was the case, we do know that he was left alone in the imaging room, and we're not sure why (so we'll use another question mark). Additionally, nurse testimony shows that the patient was disoriented and confused, which could have led to him attempting to get off the x-ray table.
Now we have included all the known (and some surmised) information and evidence on the Cause Map. We can go back and add in the other impacted goals, which results in the below Cause Map. You'll see that even though we seem to be missing a lot of information, there's still a lot to look at on the Cause Map. Additionally, we have significantly aided the investigation by showing the areas where more information is needed (denoted by question marks).
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 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. It is easier to identify many possible solutions from the detailed Cause Map than from an oversimplified high level analysis. Some solutions to the specific causes from this incident are shown below with the causes they control.
Although this Cause Map shows an analysis of one particular patient fall incident, the solutions (action items) outlined can be put into place at any healthcare facility to prevent falls, and other incidents. A one-page PDF showing the entire investigation on one page can be downloaded by clicking "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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