PDF 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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