Going Down the Tubes: A Multidisciplinary Root Cause Analysis on a Patient Safety Event Involving Delayed Transfusions

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4988-4988
Author(s):  
Yuho Ono ◽  
Pamela Stravitz ◽  
Yael Heher ◽  
Monique Mohammed ◽  
Kerry O'Brien ◽  
...  
Keyword(s):  
Patient Safety ◽  
Conflicts Of Interest ◽  
Multiple Root ◽  
Root Cause Analysis ◽  
Blood Products ◽  
Contributing Factors ◽  
Cause Analysis ◽  
Root Cause ◽  
Safety Event ◽  
Reliable Performance

Background The pneumatic tube delivery system (PTDS) has been an integral part of blood bank (BB) operations at our institution ever since its implementation in the early 2000s. Its reliable performance is essential for rapid and accurate delivery of blood products, impacting patient safety and product integrity. However, malfunctioning operational events are not uncommon given PTDS complexity and hospital-wide utilization. In 2018, 33 of 285 (12%) blood products were wasted due to PTDS events at our institution. Here we review the root cause analysis (RCA) of a patient safety event involving delayed transfusions and a wasted blood product causing temporary harm to two patients. Methods Two patients, both hospitalized on the same floor, simultaneously experienced significant delays in red blood cell (RBC) transfusions. One patient with active bleeding experienced a 2-hour delay and another patient with anemia experienced a 50-minute delay before appropriate transfusion occurred. The two patients did not receive their transfusions until their nurses physically retrieved RBC units from the BB. An incident report was filed by a floor nurse, which prompted a RCA involving the laboratory quality and patient safety team, the BB, the hospital maintenance department overseeing the PTDS, and the information systems service controlling programming of the PTDS. Results Operational challenges surrounding the PTDS were central to the multiple root causes identified (see Table). RBC units sent to the floor from the BB were electronically directed to another floor or returned to the BB, which resulted in a waste of one RBC unit. Despite multiple potential contributing factors identified, deeper investigation did not uncover evidence for any specific root cause and the electronic tube transaction history showed normal PTDS operations during the time of the incident, with all transactions appearing as successfully completed within expected timeframes. Neither of the patients involved in this safety event experienced permanent harm. The findings of this investigation were reviewed at our departmental Pathology Morbidity and Mortality conference together with stakeholders from hospital maintenance. Conclusion The root causes for PTDS technical malfunctioning leading to this safety event remain uncertain despite a collaborative RCA. This multidisciplinary retrospective RCA process, however, provided an opportunity for greater awareness of the complex mechanism of the PTDS, promoted awareness of the roles of the various stakeholders involved, and fostered interdepartmental collaboration to prevent future patient safety incidents using quality improvement principles. Table Disclosures No relevant conflicts of interest to declare.

Mass School Shootings in the United States: A Novel Root Cause Analysis Using Lay Press Reports

2019 ◽  
Vol 58 (13) ◽  
pp. 1423-1428 ◽  
Author(s):  
Chris A. Rees ◽  
Lois K. Lee ◽  
Eric W. Fleegler ◽  
Rebekah Mannix
Keyword(s):  
United States ◽  
Environmental Factors ◽  
Root Cause Analysis ◽  
The United States ◽  
School Shootings ◽  
Contributing Factors ◽  
Mass Shootings ◽  
Cause Analysis ◽  
Factors Associated ◽  
Root Cause

School shootings comprise a small proportion of childhood deaths from firearms; however, these shootings receive a disproportionately large share of media attention. We conducted a root cause analysis of 2 recent school shootings in the United States using lay press reports. We reviewed 1760 and analyzed 282 articles from the 10 most trusted news sources. We identified 356 factors associated with the school shootings. Policy-level factors, including a paucity of adequate legislation controlling firearm purchase and ownership, were the most common contributing factors to school shootings. Mental illness was a commonly cited person-level factor, and access to firearms in the home and availability of large-capacity firearms were commonly cited environmental factors. Novel approaches, including root cause analyses using lay media, can identify factors contributing to mass shootings. The policy, person, and environmental factors associated with these school shootings should be addressed as part of a multipronged effort to prevent future mass shootings.

Improving Root Cause Analysis of Patient Safety Events in Radiology

Radiographics ◽  
2020 ◽  
Vol 40 (5) ◽  
pp. 1434-1440
Author(s):  
Ashley S. Rosier ◽  
Laura C. Tibor ◽  
Mara A. Turner ◽  
Carrie J. Phillips ◽  
A. Nicholas Kurup
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

Outcomes From Root Cause Analysis of Hospital-Associated Thrombosis Over Twelve Months: A Single Centre Experience

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 675-675
Author(s):  
Lara N Roberts ◽  
Raj K Patel ◽  
Lynda Bonner ◽  
Roopen Arya
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Cause Of Death ◽  
Conflicts Of Interest ◽  
Bleeding Risk ◽  
Root Cause Analysis ◽  
Medical Patients ◽  
Advanced Malignancy ◽  
Cause Analysis ◽  
Root Cause

Abstract Abstract 675 The national Venous Thromboembolism (VTE) Prevention Programme in England incorporates standardised guidance on risk assessment (RA) and thromboprophylaxis (TP) with a requirement for root cause analysis of all episodes of hospital associated thrombosis (HAT), defined as any VTE occurring whilst an inpatient or within 90 days of discharge. We report findings from audit of root cause analysis of HAT over 12 months at King's, a major London tertiary centre with 900 beds and an estimated 53 000 admissions per annum. 239 episodes of HAT were identified associated with surgical, medical and obstetric admission accounting for 101 (42.3%), 133 (55.6%) and 5 (2.1%) cases respectively. The estimated incidence of HAT is 4.5 per 1000 admissions. The mean age of patients with HAT was 62.7 (+/− 16.8) years, with males accounting for 53.6% of the cohort. HAT manifested as deep vein thrombosis in 121 (50.6%) and pulmonary embolism in 128 (49.6%). The median time to diagnosis of HAT following admission was 16 days (IQR 7–30). 171 (67.4%) of HAT occurred prior to discharge. Of the 78 (31.7%) events occurring post discharge, 60 (76.9%) required readmission for management of HAT and 2 (2.6%) represented with fatal events. HAT was associated with mortality in 51 cases (21.3%), with death directly attributable to PE in 16 (6.7%). The estimated incidence of HAT associated with fatal PE is 0.3 per 1000 admissions. Of note, autopsy was undertaken in 12/51 with PE identified as the primary cause of death in 11/12 (2/12 had known/suspected VTE prior to death). The five remaining patients with PE as the primary cause of death had the diagnosis made on clinical suspicion alone in four cases and radiological imaging in one case. The remaining deaths were attributed to other causes in 25, with 15 having unknown cause of death as certification occurred in the community (10 with known advanced malignancy at discharge). Root cause analysis has been completed for 149 (62.3%) of HAT episodes. Of these, 43.9% had RA undertaken on admission to hospital. Retrospective RA revealed 91.0% of patients were at high risk for VTE with 33.1% also at high risk of bleeding. 72% were prescribed anticoagulant TP. Anticoagulant prophylaxis was prescribed for 30/49 (61.2%) medical, 33/36 (91.7%) surgical and 3/4 (75%) obstetric HAT cases with a high VTE risk and low bleeding risk. Of those with a high bleeding risk, 8/23 (34.8%) and 15/27 (55.6%) medical and surgical patients respectively received anticoagulant TP for part of their admission. Mechanical TP was prescribed for 41/63 (65.1%) surgical, all obstetric (4) HAT cases and 5/15 (33.3%) medical patients in whom mechanical TP was indicated and appropriate. HAT was attributed to inadequate TP in 51 (32.5%), contraindication to chemical TP in 23 (14.6%), contraindication to all TP in 11 (7.0), TP failure in 43 (27.4%), line associated in 20 (12.7%), and was considered unexpected in 9 (5.7%) patients without any risk factors for VTE. Inadequate TP resulted from failure to prescribe in 17 (33.3%), unexplained delay in initiation in 8 (15.7%), unexplained missed doses in 7 (13.7%), inadequate duration of TP in 5 (9.8%) or inferior agent or dose in 9 (17.6%) cases with a combination of the above in 5 (9.8%) cases. Mortality associated with inadequate TP was 21.6% with death directly attributable to PE of 5.9%. TP remains underused in cases of HAT, with lowest rates associated with medical admission. At our centre, improved RA and TP could reduce the annual incidence of HAT by an estimated 21%. Further research is required to improve risk assessment and thromboprophylactic strategies to address unexpected events and those arising despite optimal TP. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Severe Ventral Erosion of Penis Caused by Indwelling Urethral Catheter and Inflation of Foley Balloon in Urethra—Need to Create List of “Never Events in Spinal Cord Injury” in order to Prevent These Complications from Happening in Paraplegic and Tetraplegic Patients

2010 ◽  
Vol 2010 ◽  
pp. 1-5 ◽  
Author(s):  
Subramanian Vaidyanathan ◽  
Bakul M. Soni ◽  
Peter L. Hughes ◽  
Gurpreet Singh ◽  
Tun Oo
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Patient Safety ◽  
Root Cause Analysis ◽  
Urethral Catheter ◽  
Learning System ◽  
Cause Analysis ◽  
Root Cause ◽  
Cord Injury ◽  
Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” (i) Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter; (ii) incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra. If a Never Event occurs, health professionals should report the incident through hospital risk management system to National Patient Safety Agency's Reporting and Learning System, communicate with the patient, family, and their carer as soon as possible about the incident, undertake a comprehensive root cause analysis of what went wrong, how, and why, and implement the changes that have been identified and agreed following the root cause analysis.

scholarly journals Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis

2019 ◽  
Vol 4 (5) ◽  
pp. e200 ◽  
Author(s):  
Lane F. Donnelly ◽  
Tua Palangyo ◽  
Jessey Bargmann-Losche ◽  
Kiley Rogers ◽  
Mathew Wood ◽  
...  
Keyword(s):  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Safety Event

Anatomic Pathology Databases and Patient Safety

2005 ◽  
Vol 129 (10) ◽  
pp. 1246-1251 ◽  
Author(s):  
Stephen S. Raab ◽  
Dana M. Grzybicki ◽  
Richard J. Zarbo ◽  
Frederick A. Meier ◽  
Stanley J. Geyer ◽  
...  
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Error Reduction ◽  
Design Quality ◽  
Cause Analysis ◽  
Root Cause ◽  
Anatomic Pathology ◽  
Sources Of Error ◽  
Error Frequency ◽  
Project Site

Abstract Context.—The utility of anatomic pathology discrepancies has not been rigorously studied. Objective.—To outline how databases may be used to study anatomic pathology patient safety. Design.—The Agency for Healthcare Research and Quality funded the creation of a national anatomic pathology errors database to establish benchmarks for error frequency. The database is used to track more frequent errors and errors that result in more serious harm, in order to design quality improvement interventions intended to reduce these types of errors. In the first year of funding, 4 institutions (University of Pittsburgh, Henry Ford Hospital, University of Iowa, and Western Pennsylvania Hospital) reported cytologic-histologic correlation error data after standardizing correlation methods. Root cause analysis was performed to determine sources of error, and error reduction plans were implemented. Participants.—Four institutions self-reported anatomic pathology error data. Main Outcome Measures.—Frequency of cytologic-histologic correlation error, case type, cause of error (sampling or interpretation), and effect of error on patient outcome (ie, no harm, near miss, and harm). Results.—The institutional gynecologic cytologic-histologic correlation error frequency ranged from 0.17% to 0.63%, using the denominator of all Papanicolaou tests. Based on the nongynecologic cytologic-histologic correlation data, the specimen sites with the highest discrepancy frequency (by project site) were lung (ranging from 16.5% to 62.3% of all errors) and urinary bladder (ranging from 4.4% to 25.0%). Most errors detected by the gynecologic cytologic-histologic correlation process were no-harm events (ranging from 10.7% to 43.2% by project site). Root cause analysis identified sources of error on both the clinical and pathology sides of the process, and error intervention programs are currently being implemented to improve patient safety. Conclusions.—A multi-institutional anatomic pathology error database may be used to benchmark practices and target specific high-frequency errors or errors with high clinical impact. These error reduction programs have national import.

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