Foreign Object Retained After Surgery
Cause Mapping Example:
Leaving a foreign object within a patient's body after surgery is now considered a non-reimbursable hospital-acquired condition. It's also a "never event". We will use foreign object retention as an example of how the Cause Mapping process can be applied to a specific incident. 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? Here, the issue being discussed is a foreign object being retained after surgery. We write this down on the first line.
Next is the "when". We are making doing a proactive root cause analysis, rather than discussing a specific incident. What this means is we'll be analyzing how this issue COULD happen, rather than what DID happen as a result of a specific incident. So for the when, we'll just capture that this is a proactive Cause Map.
There are two parts to the "where". FIrst, where is the physical location that the problem occurred? Here, it's within a patient's body. Second, what work or task was being done when the problem occurred? The problem we're discussing here is a result of surgery.
Next we define the issue in context with the organization's goals. If the issue impacts an organizational goal, we capture that impact on the outline. The patient safety goal is impacted because there is the potential for death or serious injury from leaving a foreign object inside a patient's body. The compliance and organizational goals are impacted because this is a "never event". The patient service goal is impacted because the retention of a foreign object is considered a hospital-acquired condition. Last but not least, the average costs incurred as a result of the retention of a foreign object, which are no longer reimbursable under Medicare/Medicaid is over $63,000 (Center for Medicare & Medicaid Services [CMS] data). There may be impacts to the other goals for specific incidents, but for now we'll leave them blank. (Your organization can create its own customized goals section for any incident.)
Finally we come to the frequency of the incident. Again according to CMS data, there are approximately 750 cases of retained foreign objects a year. Only considering the hospital expenses, retained foreign objects cost more than $47 million a year. Shown below is the outline for retained foreign objects.
Step 2. Identify the Causes (The Analysis)
In the analysis step, 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 foreign object retention, we begin with the patient safety goal, which is impacted because of the potential for serious injury or death. This is the first cause-and-effect relationship in the analysis.
The analysis can continue by asking Why questions and moving to the right of the cause-and-effect relationship above. Since we've begun with the impact to the patient safety goal, the next question is “Why is there the potential for serious injury or death?”
The Cause Map shown above is accurate, but it's also simplified. If this Cause Map was presented, you would probably hear, "There's more to it than that." We can continue the analysis by continuing to ask "Why" questions but also by creating branches, where more than one cause is required to produce the effect (joined with "AND") or where more than one cause could produce the effect (joined with "OR"). In a proactive Cause Map such as this one, "AND/OR" is frequently used to show that one or several causes could contribute to produce the effect. A Cause Map with additional detail added is shown below.
Now that we have added some detail to our Cause Map, we can go back and put in the other impacted goals. Now our Cause Map looks as shown below.
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 the oversimplified high level analysis. Solutions are added directly to the Cause Map, above the cause they control. Shown below is an example of a cause with corresponding solution.
Shown below is the full Cause Map, with 22 causes and solutions.
Once the solutions have been determined, they are added to the Action Items list and assigned. The Action Items list for this issue is shown below.
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 patient safety, environmental, compliance, and equipment issues.
Click on "Download PDF" above to download a PDF showing the Cause Map and Process Map.
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