Patient Receiving Compressed Air Instead of Oxygen
Cause Mapping Example:
The truth of the matter is that sometimes people make mistakes. However, sometimes allowing these mistakes to occur is unacceptable because of their impact on human health. This is often the case with healthcare situations. But instead of expecting healthcare personnel to be perfect, all the time, we need to make it more difficult for mistakes to be made, and make sure that adequate oversight allows mistakes to be caught before they affect patient safety.
Here's an example of where equipment made it easier to make mistakes. In this situation, a patient was given compressed air through an oxygen mask. Delivering the wrong gas, or contaminated gas to a patient is a never event. It also has the potential for patient injury, or death. Luckily, in this case, there was no lasting effect. We'll examine this scenario in a root cause analysis, so we can learn from the mistakes of others. 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.
First, we define the problem in an outline (shown on the downloadable PDF). The issue is delivering compressed air where oxygen should be. This results in a potential for injury, an impact to the patient services goal, and an impact to the compliance goal. since this is a never event.
We use the impacts to the goals to perform our analysis, or make a Cause Map. The compressed air was in the oxygen mask because the mask was accidentally hooked up to an air flowmeter instead of an oxygen flowmeter. A mistake was made, but that mistake was made easier by interchangeable, universal adapters, and flowmeters that were difficult to tell apart.
Once we've identified the causes of the situation, we can look for situations. Many organizations here would turn to training of the involved personnel. However, we had no evidence in this case that they were unaware of what they should have been doing; the situation just made it too easy to allow for mistakes. So, instead, we look at situations that would make it much more difficult for this mistake to happen again. We could change the adapters so that it would be very difficult to hook the mask up to a compressed air flowmeter. We could change the look of the flowmeters so they are more easily identifiable.
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.
Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.
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