Question

A 32-year-old man with type 1 diabetes comes to the emergency department with malaise, fatigue, and abdominal pain.  His wife says that over the past 24 hours he has consumed large amounts of water and urinated frequently.  On physical examination, the patient has dry mucous membranes.  Laboratory testing confirms diabetic ketoacidosis.  Shortly after admission, the patient suffers a seizure after accidentally receiving a bolus of insulin 10 times the amount indicated.  He is transferred to the intensive care unit, where he experiences a ventricular arrhythmia and dies despite resuscitative measures.  His wife is inconsolable and says that she plans to sue the hospital for her husband's death.  The hospital administration enlists a team to perform a root cause analysis.  Which of the following is the first step in performing this analysis?

Accepted Answer

Explanation: 11ec2b69_c0d8_b1fd_8f63_63a679579845_MD0005_00 Medical errors present considerable risk to patient safety. Within large systems of care, checks and balances exist to prevent or minimize medical errors and resulting adverse events. Unfortunately, these safety systems may fail, requiring an examination of what occurred to prevent future events. A root cause analysis is a quality improvement tool used to identify what, how, and why an undesirable outcome occurred. When investigators determine why an event or failure occurred, they can recommend corrective measures to prevent future occurrences. Root cause analysis requires 5 steps (Table). The first step involves collecting data to have complete information about the event. In this case, it involves gathering information about the events leading up to the adverse outcome, including such steps as entering of the insulin order, review of the order by the pharmacy, and dispensing and administration of the medication by nursing staff. Data collection often includes interviewing multiple individuals involved to understand how and why the adverse outcome occurred. The second step involves creating a flow chart with causal factors, or contributors that, if eliminated, could have prevented the outcome or reduced its severity (ie, human error) (Choice C). The third step involves identifying the reasons behind each causal factor, termed the root cause. This step helps investigators understand why particular causal factors exist or occurred. For example, the pharmacist may have accidentally dispensed the wrong amount of insulin (causal factor), citing that the pharmacy has been understaffed due to budget cuts (root cause). This would have required the pharmacist to fulfill orders in a more hurried manner, increasing vulnerability to mistakes. The fourth step involves generating recommendations and implementing them. An example is having a pharmacist present on the medical floor to double-check orders (Choice E). The fifth step requires assessing the success of implemented changes. (Choice A) An autopsy may be helpful in determining the physical causes that led to the patient's death. However, it would not indicate the reason that he was accidentally given the wrong dose of insulin. (Choice B) Contacting hospital risk management may be reasonable to manage a potential lawsuit by the patient's wife; however, this is not part of the root cause analysis. Educational objective: Root cause analysis is a quality improvement tool that systematically identifies factors leading up to an adverse event within a system of care. Root cause analysis involves several steps that include data collection, identification of causal factors, identification of root causes behind causal factors, and recommendations for preventing recurrence. References: A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. (http://www.ncbi.nlm.nih.gov/pubmed/23367650) Applying root cause analysis to promote the medication safety of continuous drug infusions for infants. (http://www.ncbi.nlm.nih.gov/pubmed/24677005) The nature and causes of unintended events reported at ten emergency departments. (http://www.ncbi.nlm.nih.gov/pubmed/19765275)

Exam 1: Advanced Clinical Medicine