Flawed Decision Process and the Deadly Sproutbreak

ecoli sproutbreak

Why did it take so long to discover the source of the deadly outbreak of E.coli poisoning in Germany? Since the start of the outbreak, 35 people have died, over 100 will need kidney transplants or life-long dialysis, more than 3,000 people are ill, and falsely-accused Spanish cucumber producers have lost millions of Euros.

Researchers initially relied on the most obvious source of data: the tests carried out on suspect food. Unfortunately, the thousands of tests on farms throughout the country came up negative, even in the organic farm in Lower Saxony that now seems to be at the cause of the problem. They also carried out two surveys. The first showed that people who consumed raw tomatoes, cucumbers, and lettuce were more often sick than the others, and another case study showed a strong association between the consumption of foods from the salad bar and E. coli infection – but this wasn’t enough to narrow down the origin of the outbreak.

It was only when a detailed cohort study was carried out, including one group of nineteen Swedes that had all eaten in the same restaurant, that the data showed that those who had eaten the sprouts were nine times as likely to have gotten sick.

According to Daryll E. Ray & Harwood D. Schaffer:

“To ascertain the consumption of raw fruit and vegetables by patients and controls more objectively and less dependently on memory, RKI used the following approach in the ‘recipe-based restaurant cohort study:’ Five groups (travel groups, clubs, etc.) that comprised a total of 112 participants and included 19 individuals who acquired EHEC infection were questioned regarding the foods they consumed after eating in a common restaurant. Additionally, the menus ordered by the participants were identified by means of order lists and meal receipts. The restaurant kitchen was questioned in detail regarding the preparation and the type and quantity of ingredients in each menu ordered by any of the study participants. Furthermore, available photographs taken by travel group members were analyzed to confirm which food items, including toppings, were seen on the plates. The data thus gathered was analyzed in a cohort approach that permits the retrospective estimation of the relative risk of infection for the restaurant customers. Results of this analysis showed that customers who ate sprouts had an 8.6-fold increased risk [of] illness compared to those who did not. This study also revealed that 100% of those who contracted the illness had eaten sprouts.”

The decision process was made all the more difficult because it appears some records were held on paper rather being completely computerized, and health authorities were sometimes communicating with hospitals and each other via letters in the post rather than electronically, and were having trouble tracking who had become ill.

An overly-manual and confused decision-making process hindered the discovery of the “sproutbreak” that lead to so much suffering and hardship. But at least some good has come out of it: a better process, and a more detailed questionnaires will now be a standard part of outbreak investigation in the future.

All organizations need to be able to document and improve their decision-making processes, even if (thankfully) it’s rarely a case of life or death. Technologies like SAP Streamwork are starting to allow companies to apply standard templates to frequently-occurring decisions, and collaborate to come to the best conclusions, using an on-demand platform.

Could you improve decision-making in your organization by optimizing decision collaboration?

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One Reply to “Flawed Decision Process and the Deadly Sproutbreak”

  1. Timo,
    For companies, there are two major issues. The first is “ingredients”. When you have a product that has a mix of interconnected ingredients (or components, etc.), it becomes more difficult to localize the cause in quality issues.
    The second is supply chain. Take that problem with dog food, several years back. A tainted basic ingredient from one supplier eventually ended up in a wide variety dog food from a number of vendors. That meant that a lot of different brands of dog food were tainted at the same time.
    Finding patterns and uncovering the source means having the detail of metrics and information that can be easily accessed and shared across different vendors. The more complex the ingredients and the supply chain, the more data that is needed to be calculated quickly.
    Something like StreamWork could be a very effective way of collaborating both internally and externally, by better collaboration between departments, suppliers, and other vendors.

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