Using A3 Methodology to Identify the Root Cause of a Chemotherapy Error in a Hematopoietic Stem Cell Transplant Patient

Introduction: Chemotherapy errors in the hematopoietic stem cell transplant (HSCT) setting cause significant non-hematologic morbidity and mortality. The existing “shame and blame” culture prevents error reporting, promotes “work around” solutions, and fails to identify root causes. The University of Virginia Health System implemented LEAN principles and the A3 problem solving tool to identify problems related to patient and employee safety, and focus on system issues versus human error in order to standardize work, eliminate waste and increases efficiency of healthcare delivery.

 

Objective: To report the A3 analysis of a chemotherapy error in which a HSCT patient scheduled for reduced intensity fludarabine/busulfan conditioning chemotherapy received 10 busulfan doses instead of the 8 intended.

Methods: A multidisciplinary team was assembled including a process coach. The A3 rigor was applied to: 1) Directly observe the disciplines who provided the care then visually illustrate the algorithm of the current state for the ordering, verification and administration of chemotherapy;  2) Identify the problem statement and associated violations in Rules of Use (figure 1); 3) Identify the goal/target state; 4) Analyze to root cause by asking cascading “why” questions starting with the problem statement; 5) Identify/implement countermeasures to the root cause; 6) Measure outcomes.

 

Results: The current condition is illustrated in figure 2. Storm clouds indicate violations in Rules of Use. The problem statement was "a patient received 2 unintended doses of chemotherapy" and the identified root cause was the use of a drug record not configured to the standard treatment plan leading to the omission of therapy duration (activity rule violation). Other contributing causes were non-standard work and unclear communication regarding the correct duration (connectivity rule violation).   To achieve the target condition that “patients will always receive the intended duration of chemotherapy”, the following countermeasures were proposed: 1) Configure a hard stop in the chemotherapy drug records to add duration for safe use outside of the standard treatment plan template; 2) Standardize communication so all providers are aware of the intended treatment plan; 3) Create reports in the electronic medical record to standardize the work involved in the process of prescribing, verification and administering chemotherapy. 

 

Conclusions: The A3 method allowed for rapid identification of the root cause and implementation of target workflow. Countermeasures have been identified and are currently being implemented. Implementation of the identified countermeasures will be assessed to ensure all chemotherapy orders have appropriate durations, including appropriate follow up adjustments to the process as needed.