Review the case at the U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research, “Getting to the Root of The Matter”...

Review the case at the U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research, “Getting to the Root of The Matter” at https://psnet.ahrq.gov/webmm/case/98/getting-to-the-root-of-the-matter

  1. Define a root cause analysis and when it is used.
  2. In the case study identify the incident and explain the problem that might trigger a root cause analysis.
  3. Do you agree that the problem should not be investigated? Explain why or why not?
  4. Discusses the goals and limitations of root cause analysis;
  5. Outline the steps to conduct a root cause analysis.
Expert Answers
jameadows eNotes educator| Certified Educator

A root cause analysis takes place when a team of experts that is not directly involved in an event examines a serious adverse event or a close call that occurred during treatment of a patient in a healthcare setting. The investigation is intended to reveal what happened, why it happened, and how this event could be prevented in the future.

In this case, the incident that triggered a root cause analysis was that the patient suffered a myocardial infarction (MI) that was probably the result of a prescribing error. The problem should be investigated, as the patient was receiving the wrong dose of medication (according to the article, "the patient had been receiving 0.4 units/min of vasopressin, rather than the intended dose of 0.04 units/min"). The reason for this error should be investigated so it can be prevented in the future. 

The steps necessary to conduct the root cause analysis are to produce a timeline to investigate why the patient received the wrong dose of medication, analyze contributing factors, and come up with systems solutions to prevent this error from occurring in the future. The goals are to reduce errors in treating patients, and the limitations are that the proposed solutions have to be doable and not waste clinicians' time or prove to be ineffective.