summary - thinkreliability...case study step 2. cause map received 2 pints blood (wrong blood type)...

Healthcare Case Study: Blood Incompatibility

Copyright ThinkReliability 1

Cause MappingCause MappingCause MappingCause MappingProblem Solving • Incident Investigation • Root Cause Analysis

Angela Griffith, [email protected] 281-412-7766Houston, TX

Healthcare Case Study

ABO Blood Incompatibility

®

Summary

Problem Investigation Overview

Proactive/ Cumulative Example

Process Map: Blood Transfusion

Case study

Questions



3

1. What’s the problem?

2. Why did it happen?

3. What should we do?

1. Problem

2. Analysis

3. Solutions

Basic Investigation Steps


4Copyright ThinkReliability 2013

1. Problem

2. Analysis

3. Solutions

Cause Mapping

Problem Solving Steps

What

When

Where

GOALS

Step 1. Define the Gaps

Step 2. Identify the Causes

Step 3. Determine Solutions

What’s Possible?

SolutionCause Owner Due DateNo.

Specific Action Plan

®

What’s Effective? (Select the Best)

Start simple

Add detail as needed

Why? questions

Add evidence as needed

Cause Map



5Copyright ThinkReliability 2013

Process MapsThe specific steps of a work process.

When a process doesn’t produce the desired results the question is “Why?”

Cause MapsThe causes of a problem.

The work process defines how the organization would like to conduct its business every day.

The Cause Map is a visual explanation of why the organization didn’t get the desired results from their work process.

1. Problem

2. Analysis

3. Solutions

A B

Solutions from an investigation make specific improvements in the work process.

Plan

Do

Check

Act

Plan-Do-Check-Act

Cause Mapping®

TWO TYPES OF CAUSE MAPS

REACTIVE PROACTIVE

Did happen (past - incident)

Could happen (future – potential incident)

This is what is known as a Cumulative Cause Map



Cause Mapping®

Step 1. Outline – Proactive Map

What Problem(s)

When Date

Differences

Where Physical Location

Unit/Process/Equipment

Work/Task Being Done

Impact to the GoalsPatient Safety

Employee Impact

Compliance

Organization

Patient Services

Materials, Labor

Frequency

Patient death or serious disabilityProactiveABO-incompatible blood, blood productHospital, medical centerDonated blood, blood productAdministration of blood, blood product

Patient death, serious disability“Second victim”

“Never event”Hospital-acquired conditionTransfusion of incompatible productNon-reimbursable cost of care $50,455

Risk of error during transfusion 1:16,500

Risk of ABO incompatible transfusion 1:100,000

Risk of death as result 1:1,500,000

Proactive Map

Step 2. Cause Map

Hemolytic

reaction

Patient Safety

Goal Impacted

Patient death,

serious

disability

Patient given

ABO-

incompatible

blood/product



Proactive Map

Step 2. Cause Map

Patient given

ABO-

incompatible

blood/product

Blood product

type identified

incorrectly

Blood product

mislabeled

Recipient’s

blood type

identified

incorrectlySpecimen

mislabeled

OR

Blood product

given to wrong

recipient

Incorrect

identification

of recipient

OR

Incorrect

identification

of patient

OR

Process Map – Blood Transfusion

Transfusion

ordered

Obtain

specimen from

patient

Prep patient

for transfusion

Test specimen

from patient

Obtain blood

product from

blood bank

Blood product

deposited into

blood bank

Blood transfer

to patient



Process Map – Obtain Specimen from Patient

Identify patient

(2 identifiers)

Obtain blood

specimen

Label

specimen

bedside

Send

specimen to

lab

Specimen mislabeled

Patient mis-identified

Process Map – Blood Product Deposited into Bank

Verify identityCollect blood

sample

Test for blood

group,

antibody

screening

Blood product

labeled

Product mislabeled

Blood product

stored



Process Map – Blood Transfer to Patient

Match blood

product to

provider’s

order

Match blood

product to

patient

Sign, date and

time blood

bank slip

Hand hygiene,

gloves

Patient misidentified

Attach blood

product to

delivery

system

Obtain vital

signs

Patient follow-

up for reaction

Proactive Map

Step 3. Solutions

Patient given

ABO-

incompatible

blood/product

Blood product

type identified

incorrectly

Blood product

mislabeled

Recipient’s

blood type

identified

incorrectly

Specimen

mislabeled

OR

Blood product

given to wrong

recipient

Incorrect

identification

of recipient

OR

Incorrect

identification

of patient

OR

Solution: Label

bedside in view of

donor

Solution: Label

bedside in view of

patient

Solution: Bar-

coding, use of

photo ID

Solution: Patient

identification process



What Problem(s)

When Date

Differences





Employee Impact

Patient Services

Compliance

Organization

Materials, Labor

This incident

Frequency

Cause Mapping®

Step 1. Outline – Case Study

Patient death, blood infusion

July 22, 2015

Blood sample taken from roommate

Falls Church, Virginia

Trauma center

Blood transfusion during bowel resection

Patient death

Worker resigned; distraught

Blood not available for other patients

“Never event”, voluntary reporting

Potential for lawsuit

Numerous treatments, investigation

?

14 deaths due to hospital blood error in 2002

?

Case Study

Step 2. Cause Map

Acute

hemolytic

transfusion

reaction

Patient Safety

Goal ImpactedPatient death

Received 2

pints of blood

(wrong blood

type)



Process Map – Obtain Specimen from Patient

Identify patient

(2 identifiers)

Obtain blood

specimen

Label

specimen

bedside

Send

specimen to

lab

Patient mis-identified

Case Study

Step 2. Cause Map

Received 2

pints blood

(wrong blood

type)

Patient blood

type

incorrectly

determined

Blood type

testing from

wrong patient

Ineffective

identification

process

Patients

switched beds

AND



Case Study

Step 2. Cause Map

Received 2

pints blood

(wrong blood

type)

Patient blood

type

incorrectly

determined

Blood type

testing from

wrong patient

Ineffective

identification

process

Patients

switched beds

AND

Solution: 2nd

person

accompanies

technician to

drawn blood for

cross-matching

What Problem(s)

When Date

Differences





Employee Impact

Patient Services

Compliance

Organization

Materials, Labor

This incident

Frequency

Cause Mapping®

Step 1. Outline – Case Study

Patient death

2003

Patient O, organs A

North Carolina

Pediatric intensive care unit

Organ transplant- heart, lungs

Patient death

Surgeon devastated

Organs not available for other patients

“Never event”

Settlement

Cost of surgery, hospital stay

Undisclosed

Very rare

$1 million



Case Study

Step 2. Cause Map

Rejected

transplanted

organs

Patient Safety

Goal ImpactedPatient death

Transplanted

organs with

incorrect

blood type

Case Study

Step 2. Cause Map

Transplanted

organs with

incorrect

blood type

Organs with

incorrect blood

type delivered

to OR

Did not check

compatibility

in OR

AND

Laboratory did

not notify OR of

blood mismatch

until too late

AND

No protocol for

checking

blood type of

organs in OR

Surgery

begins while

organs en-

route

Limited

viability of

organs

Testing

performed

after organs

arrive

AND



Case Study

Step 2. Cause Map

Organs with

incorrect blood

type delivered

to OR

Procuring

surgeon did not

know recipient’s

blood type

Donor services

offered organs

with incorrect

blood type

AND

Assumed surgeon

would not request

organs of wrong

blood type

Surgeon did not

verify blood type

of organs

AND Assumed donor

services would

not offer organs of

wrong blood type

Surgeon

exhausted (call

came at 3 AM

while asleep)

AND

No. Cause Action Item1

2

3

4

5

Cause Mapping®

Step 3. Solutions – Case Study

No protocol for checking blood type of organs in OR

Lab did not notify of mismatch until too late in surgery

Procuring surgeon not told recipient’s blood type

Donor services offered organs with incorrect blood type

Surgeon did not verify blood type of organs

Create protocol

Send lab personnel to pickup

Ensure procuring surgeon can match blood types

Always match blood types (already a requirement)

Always match blood types (already a requirement)

summary - thinkreliability...case study step 2. cause map received 2 pints blood (wrong blood type)...

Documents