Wrong Surgical Procedure Performed on Patient
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 receiving the wong medical procedure 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.
Background
The patient had been previously treated at a different hospital for a possible fracture of her right ankle. She returned to a different hospital for unrelated issues and was given an ankle radiograph when her previous records did not arrive from the first hospital in a timely manner. The radiograph indicated a fracture, and the patient was prepped for surgery and given spinal anesthesia. Prior to performing the procedure, the orthopedist noticed that it was a radiograph of a left ankle. New radiographs were taken of both ankles, and the right ankle showed a healing fracture. The left ankle was intact. It waas later determined that the radiographs must have belonged to a previous patient and been mislabeled. (View the
Case Study from Morbidity & Mortality Rounds on the Web.)
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? Here, one problem is that a patient nearly received an unneccessary procedure. Another problem is that the patient was administered spinal anesthesia for that unneccessary procedure. We don't have information about when the event happened, but an important "difference" is that the radiograph was mislabeled. The event happened in the operating room of a hospital while the patient was being prepped for surgery.
Next, we define the event with respect to the overall goals. For this event, the patient safety goal was impacted because a patient was administered spinal anesthesia for a procedure that wasn't needed. Additionally, the compliance and patient services goals were impacted because of a near miss for a never event - a patient receiving an unneccessary procedure.
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. These are the first 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. For example, why was the spinal anesthesia administered? Because the patient was being prepped for surgery. This is also what caused the near miss for a never event.
We fill out the Cause Map to the right by asking more "Why" questions. Why was the patient prepped for surgery? Because the orthopedist recommended it. Why did the orthopedist recommend surgery? Because the orthopedist believed the patient had a trimalleolar fracture in his ankle.
Why did the orthopedist believe that the patient had atrimalleolar fracture in his ankle? The orthopedist did not review the radiograph, and performed an ineffective exam. The radiologist reported the fracture, and the patient and his family did not discuss the previous diagnosis. Had any one of these causes not happened, the near-miss might have been avoided.
We don't know why the orthopedist didn't review the radiograph or perform an effective exam. But we do have some idea why the radiologist reported a fracture. The radiologist reported a fracture because the radiograph, which was labeled with the current patient's name, showed a fracture. The radiograph showed a fracture because it was of the previous patient. Possibly it was left in the radiology room. We're not sure how the radiograph got mislabeled, but the patient did have new radiographs taken, because radiographs from the previous hospital did not arrive in time.
Although we don't know exactly what happened in this case, we can make some educated guesses about why the patient and his family did not discuss his previous diagnosis. They may not have been told their previous diagnosis, or did not understand it, possibly because the diagnosis was not clearly explained, or was not written down.
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, solutions can be identified that will prevent, or reduce the risk of, the incident occurring again in the future.
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.
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