Root Cause Analysis
Root Cause Analysis
Root Cause Analysis
Tract Infections
A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
According to Medicare data, there were 12,185 cases of CatheterAssociated Urinary Tract Infections (UTIs) in the year 2007, which
resulted in an average $44,043 hospital stay. These cases represent
more than $500 million in this preventable, hospital-acquired condition.
As a result, Medicare and Medicaid will no longer cover costs
associated with UTIs if they were not present at admission to a medical
facility.
In order to work at preventing these conditions, first we must examine
how they occur. We'll do this by looking at Catheter-Associated Urinary
Tract Infections in a visual root cause analysis (or Cause Map).
A UTI is an impact to our patient safety goal. A UTI is caused by
pathogens accessing the urinary tract and not being removed. We will
look at each of these causes in more detail.
Pathogens access the urinary tract when a urinary catheter is inserted. The catheter
may be used for obtaining urine, because a patient is incontinent, or to permit urinary
drainage.
Drainage
system
contaminated
Solution: Handwashing
before and after
manipulation of catheter
site or apparatus
Permiting
urinary
drainage
OR
Catheter
inserted
improperly
Damage to
urinary tract
Non-sterile
insertion
Pathogens
not removed
from body
The pathogens are not removed from the body either because of an insufficient immune response
caused by damage to the urinary tract by improper insertion or improper securing of the catheter.
Or, the pathogens are not excreted due to an obstructed urinary flow.
Patient is
incontinent
OR
Pathogens
on hands of
medical
personnel
AND
OR
Solution: More frequent
nursing care
Solution: Consider
alternatives for urinary
drainage
OR
Pathogens in,
on catheter
Urinary tract
infections
Catheter
inserted
AND
OR
Safety Goal
Impacted
Pathogens in
body
Pathogens
access the
urinary tract
Obtaining
urine
AND/OR
AND/OR
Solution: Ensure
catheters properly
secured
Catheter
improperly
secured
Solution: Ensure free flow
of urine; keep collecting
bag below level of bladder
Pathogens
not excreted
Obstructed
urinary flow
Cause Map
Detail Level
Why?
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Effect
Cause
Once we have determined the basic causes of a UTI from our simple root cause analysis, we can
consider solutions associated with the causes. For example, if a cause is "Pathogens on hands of
medical personnel", a solution may be to require "Handwashing before and after manipulation of
catheter site or apparatus."
Here, the potential solutions are in green boxes. If facilities began implementing some or all of these
solutions, the incidence of Catheter-Associated UTIs would decrease, and patient health and
satisfaction would increase.