Healthcare Case Study: Blood Incompatibility
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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
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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
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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
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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
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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
Healthcare Case Study: Blood Incompatibility
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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
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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
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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
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What Problem(s)
When Date
Differences
Where Physical Location
Unit/Process/Equipment
Work/Task Being Done
Impact to the GoalsPatient Safety
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)
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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
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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
Where Physical Location
Unit/Process/Equipment
Work/Task Being Done
Impact to the GoalsPatient Safety
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
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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
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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)