• Read the scenario.

• Complete a Cause and Effect Diagram

• Write a post the following from your Cause and Effect Diagram:

• • Clearly written problem statement

  • List of major causes (e.g., People, Process, Equipment, Environment, etc.) and sub-causes pertinent to each major cause.

  • Most likely cause(s). This must relate directly to the problem.

SCENARIO:

Molly was excited about turning eight and the Wonder Woman themed party she had been planning with her mom, Lisa, for the past several weeks. However, her excitement was tinged with apprehension because the Wednesday after her birthday, she was scheduled for a septoplasty for turbinate reduction. She had been asking her mom about what the experience would feel like, whether she would feel pain, how she would be able to breathe, and whether she would be able to tell her friends about the surgery. Lisa did her best to answer Mollys questions and put her at ease about the surgery but felt frustrated that neither the ENT surgeon nor the hospital had provided her with information that she could draw on to answer Mollys questions. A few days ago, Lisa had received an email with links to two videos to help her prepare for Mollys surgery. One was a video about general anesthesia for adults and the other, about pediatric adenoidectomy. Lisa was puzzled because neither seemed applicable to Molly. However, she started to watch the video on anesthesia but stopped after she heard the word die for the fifth time. She did not watch the video on pediatric adenoidectomy because Google showed that an adenoidectomy was not the same as a septoplasty. The day after Mollys party, Lisa received an email with detailed instructions on preoperative preparation for Molly. It was a long, prescriptive list that included everything from preparing the skin with chlorhexidine gluconate (CHG) on the day of the surgery to not wearing any jewelry or chemicals, such as nail polish. Lisa had taken Molly for her first manicure/pedicure the day before her birthday and decided it was too soon to remove Mollys nail polish. As a working single mom, Lisa wasnt able to make the time to go to the local pharmacy to pick up the CHG. On Wednesday morning, Lisa woke Molly at 6 AM to get ready for her surgery. She tried to keep her voice calm although inwardly she felt anxious. Molly took a shower using her regular body wash. Lisa had read the NPO (nothing by mouth) guidelines and did not give Molly any breakfast. On the way to the hospital, Lisa asked Molly if she had remembered to brush her teeth; Molly said she hadnt. When they pulled into the hospital parking garage, Lisa fished for a piece of sugarless gum for Molly so that her mouth wouldnt smell bad. She found a piece and gave it to Molly. When they checked in for surgery, Lisa told the patient services representative (PSR) that she had not had a change to get the special CHG body wash and that Molly had used her regular body wash. The PSR responded rather matter-of-factly that that was okay. Lisa also realized that she had not asked Molly to remove the earrings from her newly pierced ears. The PSR told her that would not be a problem, and nor did Mollys nail polish or eating gum cause any concerns. To Lisa, this seemed odd as she wondered why all these steps had been included in instructions if they were not necessary. The ENT surgeon was running late, and Lisa and Molly had to wait for nearly two hours before Dr. Nicholas, the anesthesiologist came out to meet them. By this time, Lisas estranged husband, Dean, had also arrived and participated in the conversation with Dr. Nicholas. Molly watched TV the entire time and was not invited to participate in the conversation her parents had with Dr. Nicholas about the treatment plan for Mollys septoplasty. After Lisa had signed the consent form for Mollys surgery, Dr. Nicholas invited Dean to take Molly to the OR. Dean held Mollys hand as they walked through a maze of hallways to the OR. Mollys sense of trepidation became more heightened as she entered the OR. Under the bright lights, she saw the eyes of masked men and women who she did not recognize. Being raised in a 21st century urban environment, Molly had been taught to express her concerns if she felt unsafe, and especially if she felt that somebody was invading her personal space. Molly started to become increasingly uncomfortable and turned to Dean to ask if they could leave. She said she did not want to have the surgery and had changed her mind. The adults in the room laughed, making Molly feel more uncomfortable. She started to become more agitated when Dean did not acquiesce to her request. She felt helpless and started to whimper but no one in the room seemed to care or pay any attention to her increasing sense of anxiety. Finally, everyone in the room was ready for her to be placed on the OR table but she resisted. A masked woman tried to distract Molly by asking her if she wanted to see Frozen on her phone; Molly declined and became increasingly more resistant. Talking amongst themselves, someone in the room suggested that if she was not willing to be seated on the OR table of her own volition, she could be restrained. The atmosphere in the OR was becoming more chaotic and Dean eventually scooped up Molly, placed her on the OR table, and held her down until the face mask was firmly placed on her mouth and the sevoflurane had taken effect. Dean was visibly distraught about this incident and felt somewhat reassured when one of the masked women said Molly would not remember any of this. He then left the OR. Upon completion of the surgery, Dr. Nicholas moved Molly to the Post-Anesthesia Care Unit (PACU). As Molly started to emerge from the anesthesia, she began writhing on the bed as if she was trying to free herself from restraint. As she became more lucid and realized no one was holding her down, she stopped. However, when she saw Lisa when she was taken to her for discharge, she began crying. She refused to look at Dean or to talk to him. Lisa was puzzled because Molly loves being around her father. That night, Molly was inconsolable. She refused to sleep in her room and insisted that Lisa stay by her side. Eventually, she fell asleep but it was clear she was having nightmares as she would wake up every few minutes screaming and crying. The next morning, Molly called Betsy the OR Manager and demanded to know why Molly was showing symptoms of acute PTSD. Betsy told Lisa that she would ask the Chief Medical Officer (CMO), Dr. Hirsch to review this case and would have him call Lisa. Later that morning, Betsy called Dr. Hirsch to tell him about Lisas call. Dr. Hirsch recently stepped into the CMO role and the patient experience has been his number one priority. As a matter of routine, his hospital rarely serves the pediatric patient population and he has made it his mission to change that so that all services are pediatric-friendly. Later that morning, Dr. Hirsch logs into the hospital EHR and looks up Mollys record but does not find any mention of any events that could be caused Molly acute PTSD. He calls Drs. Nicholas and Kim (ENT Surgeon) to learn more. Dr. Kim tells Dr. Hirsch that by the time he arrived in the OR, Molly was already asleep and he did not witness any of the events leading up to her anesthetic. Dr. Nicholas recalls Molly being agitated, But shes 8 years old. Its natural, he says. He confirms that Dean held Molly down while he placed the face mask on Molly to anesthetize her and adds everyone was doing fine at the end of the surgery. Based on this information, Dr. Hirsch decides to do a root cause analysis to determine where his hospital failed Molly