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Difficulty: MediumPatient Safety and Quality Improvement

A 72-year-old man is admitted to the hospital with a complicated urinary tract infection. Urine cultures grow *Escherichia coli*. The susceptibility report indicates the organism is susceptible to narrow-spectrum oral cephalexin. The attending physician intends to prescribe cephalexin, but a recent electronic health record (EHR) system update has altered the default order sets. Due to a mapping glitch, selecting "UTI targeted therapy" auto-populates a 14-day course of broad-spectrum intravenous piperacillin-tazobactam. The physician signs the order without noticing the discrepancy, and the medication is administered. Three days later, the patient develops severe diarrhea and is diagnosed with a *Clostridioides difficile* infection. The incident is flagged for review. Which of the following is the most appropriate next step for the hospital's patient safety committee?

  1. Convene a multidisciplinary team to perform a root cause analysis of the EHR update and medication workflow.Answer
  2. B
    Issue a formal reprimand to the physician and nurse for their negligence in verifying the medication order.
  3. C
    Recommend the primary care team continue the piperacillin-tazobactam since it provides adequate coverage for the urinary tract infection.
  4. D
    Design a case-control study that selects patients based on their exposure to the new EHR update to measure the incidence of future errors.
  5. E
    Publish the unredacted incident report on the hospital intranet to rapidly alert other staff members about the EHR glitch.

Answer

The correct answer is to convene a multidisciplinary team to perform a root cause analysis of the EHR update and medication workflow.
The correct answer is to conduct a root cause analysis (RCA). RCA is a retrospective, systems-based approach used to identify the underlying systemic and environmental causes of a medical error or sentinel event. In this scenario, the adverse event was precipitated by a latent error (the EHR mapping glitch) combined with an active error (the physician failing to verify the auto-populated order). An RCA will help identify these specific vulnerabilities and lead to structural improvements, such as correcting the EHR mapping and implementing forced functions or alerts, to prevent future recurrences. This approach avoids the pitfalls of individual blame.

Step-by-Step Solution

1
Analyze the nature of the adverse event described in the vignette.
The event is a medication error caused by a combination of an EHR system glitch (a latent error) and a failure to verify the order (an active error), resulting in patient harm (*C. difficile* infection).
Understanding the interplay between system flaws and human error is essential for selecting the appropriate patient safety intervention.
2
Determine the most appropriate framework for investigating this type of event.
A retrospective, systems-based investigation is required to prevent recurrence without assigning individual blame.
Root cause analysis (RCA) is the standard quality improvement tool used to investigate sentinel events and identify structural vulnerabilities for future prevention.

Key Concept

Root Cause Analysis (RCA)
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Topics

Patient Safety and Quality Improvement

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