2 The Willie King Case: Wrong Foot Amputated Cause Mapping
2 Analysis
Patient Safety Goal Impacted
Risk from additional surgery
The Willie King Case: Wrong Foot Amputated
Other foot still required
amputation
Couldn't be saved
Severely diseased
Complications of diabetes
Cause Mapping is a Root Cause Analysis method that captures basic cause-and-effect relationships supported with evidence.
Cause Mapping
Problem Solving ? Incident Investigation ? Root Cause Analysis
Step 1.1
Problem
What's the Problem?
Additional surgery required
Schedule/
AND
Operations
Goal Impacted
Compliance Goal Impacted
"Never event"
Wrong foot Wamropnugtaftoeodt amputated
Surgeon believed he was
removing the correct foot
Patient Services Goal
Impacted
Organization Goal Impacted
Property/ Equipment Goal Impacted
Hospital and surgeon paid out
large settlements
Evidence: Hospital paid $900,000 settlement and the surgeon paid a separate $250,000 settlement to the patient.
Labor/ Time Goal Impacted
Manpower required for investigation
Bad publicity for surgeon and hospital
Dramatic medical error made many
headlines
3 Solutions
A number of changes have been incorporated in the time since this case occurred to help reduce the risk of wrong site surgery. Surgeons in Florida are now required to take a timeout prior to beginning a surgery. During the time out they are required to confirm that they have the right patient, right procedure and right surgical site. This rule has been in place since 2004.
Investigate Problems. Prevent Problems.
Houston, Texas 281-412-7766
The "good" foot looked like it needed to be amputated
AND
Wrong leg was prepped for surgery when
surgeon arrived
AND
Much of the paperwork listed
wrong leg
AND
Not required to check
paperwork that was correct
AND
Surgeon did not speak to patient
prior to amputation
"Good" foot was also severely diseased
Evidence: Other doctors stated that the second foot would probably have needed to be amputated in the future as well as the foot scheduled for surgery.
Complications of diabetes
Much of the paperwork listed
wrong leg
The blackboard in operating room listed wrong foot
AND
Operating room schedule listed
wrong foot
See same cause
Scheduler incorrectly listed
wrong foot
Step 2.2
Analysis
Step 3.3 Solutions
Why did it happen?
What will be done?
In one of the most notorious medical error examples in US history, the wrong foot was amputated on a patient named Willie King on February 20, 1995. Both the hospital and surgeon involved paid hefty fines and the media had a feeding frenzy covering the dramatic and alarming mistake.
?
AND
Hospital computer system listed wrong foot
1 Problem
Consent form and medical history noted correct foot Evidence: Investigation of the incident.
AND
No requirement to check these
forms
What When
Problem(s) Date Different, unusual, unique
Where
Facility, site Task being performed
Impact to the Goals
Patient Safety
Employee Safety
Organization
Compliance
Patient Services
Schedule/ Operations
Property/ Equipment
Labor/ Time
Wrong leg amputated February 20, 1995 Both lower legs were diseased, paperwork errors University Community Hospital, Tampa, Florida Surgery, planned amputation of diseased foot
Risk from additional surgery ? Bad publicity for surgeon and hospital "Never event" Wrong foot amputated Additional surgery required Hospital and surgeon paid out large settlements Manpower required for investigation
$1,150,000
This incident $1,150,000
Not required
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